Individual
BRENT FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3535 W 13 MILE RD STE LL, ROYAL OAK, MI 48073-6770
(248) 551-3000
Mailing address
26901 BEAUMONT BLVD STE 3D, SOUTHFIELD, MI 48033-3849
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
4301070157
MI
208000000X
Pediatrics Physician
4301070157
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110F376980
BCBSM
MI
05
—
4800002
—
MI
Enumeration date
03/21/2006
Last updated
10/05/2021
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