Provider Demographics
NPI:1801848668
Name:FULK, CHARLES SAMUEL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:SAMUEL
Last Name:FULK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E ECONOMY RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3388
Mailing Address - Country:US
Mailing Address - Phone:423-587-4600
Mailing Address - Fax:423-587-1729
Practice Address - Street 1:400 E ECONOMY ROAD
Practice Address - Street 2:SUITE 8
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3388
Practice Address - Country:US
Practice Address - Phone:423-587-4600
Practice Address - Fax:423-587-1729
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD014379174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0024632OtherBLUE CROSS
TN3715864Medicaid
TNTN0102OtherJOHN DEERE HEALTH
GA070000633OtherRAILROAD MEDICARE
TNB04780Medicare UPIN
TNTN0102OtherJOHN DEERE HEALTH