Basic Information
| Provider Information | |||||||||
| NPI: | 1063435949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLERTON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 35100 | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591075100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062382500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 10TH AVE N | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591010703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062382500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 8769 | MT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0021471 | 01 | MT | MDCD PIN | OTHER | 000001233 | 01 | MT | BCBS PIN | OTHER |