Provider Demographics
NPI:1801814702
Name:VIRGINIA S FULLER MD LLC
Entity type:Organization
Organization Name:VIRGINIA S FULLER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-690-3000
Mailing Address - Street 1:PO BOX 65457
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 COLLEGE ST
Practice Address - Street 2:ANESTHESIA DEPT @ GRANVILLE MEDICAL CENTER
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2507
Practice Address - Country:US
Practice Address - Phone:919-690-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2337812Medicare PIN