Provider Demographics
NPI:1841635133
Name:FULTON MEDICAL, P.C.
Entity type:Organization
Organization Name:FULTON MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRIGORIY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRICHMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-271-9151
Mailing Address - Street 1:200 BOUNDARY AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-1152
Mailing Address - Country:US
Mailing Address - Phone:631-271-9151
Mailing Address - Fax:
Practice Address - Street 1:200 BOUNDARY AVE
Practice Address - Street 2:STE. 200
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-1152
Practice Address - Country:US
Practice Address - Phone:631-271-9151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty