Provider Demographics
NPI:1972542488
Name:FULTON, ROGER L (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:FULTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 BROADWAY
Mailing Address - Street 2:PO BOX 181
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1960
Mailing Address - Country:US
Mailing Address - Phone:618-654-9851
Mailing Address - Fax:618-654-1339
Practice Address - Street 1:1212 BROADWAY
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1960
Practice Address - Country:US
Practice Address - Phone:618-654-9851
Practice Address - Fax:618-654-1339
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36065210207R00000X
IL036065210208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5828298OtherAETNA
116583OtherHEALTH LINK
52553OtherGROUP HEALTH PLAN GHP
0403712OtherUNITED HEALTH CARE UHC
IL006015346OtherBLUE CROSS BLUE SHIELD OF
IL036065210Medicaid
020011762OtherRAILROAD MEDICARE
35030OtherCMR A DIVISION OF GHP
IL006015346OtherBLUE CROSS BLUE SHIELD OF
5828298OtherAETNA