Provider Demographics
NPI:1396781944
Name:FULMER, GREGG S (MD)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:S
Last Name:FULMER
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 1:205 E PALMER RD
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2281
Mailing Address - Country:US
Mailing Address - Phone:937-593-0245
Mailing Address - Fax:937-592-8633
Practice Address - Street 1:205 PALMER AVE.
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2281
Practice Address - Country:US
Practice Address - Phone:937-592-4015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.081568207R00000X
OH35081568208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
341407259OtherNATIONWIDE
341407259037OtherMEDICAL MUTUAL
87726OtherUHC
FU7340041OtherTRICARE
7755544OtherAETNA
000000026809OtherANTHEM
OH2369057Medicaid
341407259OtherCIGNA
341407259OtherCIGNA
H16091Medicare UPIN
FU4096452Medicare ID - Type Unspecified