Provider Demographics
NPI:1255561775
Name:FULTON, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FULTON
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 1:2000 JOSEPH E SANKER BLVD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-1979
Mailing Address - Country:US
Mailing Address - Phone:513-841-7400
Mailing Address - Fax:513-841-7402
Practice Address - Street 1:3301 MERCY HEALTH BLVD
Practice Address - Street 2:SUITE 525
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-1118
Practice Address - Country:US
Practice Address - Phone:513-841-7700
Practice Address - Fax:513-841-7701
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094972208600000X
OH35125792208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCC2433OtherMEDICARE RR
OHCC2433OtherMEDICARE RR
OH1114950006Medicare NSC