Provider Demographics
NPI:1972545804
Name:FULLER, BARBARA L (MD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S LAKE PARK AVE
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6641
Mailing Address - Country:US
Mailing Address - Phone:219-947-1795
Mailing Address - Fax:219-947-9834
Practice Address - Street 1:1600 S LAKE PARK AVE
Practice Address - Street 2:SUITE1101
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6641
Practice Address - Country:US
Practice Address - Phone:219-947-1795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056161207RH0003X
IN01034701A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056161Medicaid
IN100394430Medicaid
IN100213850FMedicaid
INCE1551Medicare ID - Type UnspecifiedR R MCARE GROUP PROV #
IL036056161Medicaid
IN100213850FMedicaid
IL437901Medicare ID - Type UnspecifiedMCARE GROUP PROV #
IN626820Medicare ID - Type UnspecifiedMCARE GROUP PROV #
ILCA8459Medicare ID - Type UnspecifiedR R MCARE GROUP PROV #
ILL53264Medicare ID - Type UnspecifiedMCARE INDIV PROV #