Individual
DR. JERYL GLYNN FULLEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1101 MICHIGAN AVE, LOGANSPORT, IN 46947-1528
(574) 753-1729
Mailing address
1101 MICHIGAN AVE, LOGANSPORT, IN 46947-1528
(574) 753-1729
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
01063517A
IN
207X00000X
Orthopaedic Surgery Physician
04-16478
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000696600
ANTHEM
IN
05
—
100118960A
—
KS
05
—
200993900
—
IN
01
—
5N934
MEDICARE PTAN
AR
Enumeration date
09/20/2006
Last updated
01/16/2014
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