Active NPI
John M Fultz II, M.D.
- Internal Medicine Physician
- Evanston, IL
National Provider Identifier
1679664163
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- 036042979
- Practice address
- 1314 Church St
Evanston, IL 60201-3508 - Phone
- (773) 275-6349
- Fax
- (773) 275-6385
- NPI assigned
- Sep 27, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | 036042979 | IL | Primary |
Addresses
Primary practice location
1314 Church St
Evanston, IL 60201-3508
Mailing address
1314 Church St
Evanston, IL 60201-3508
Phone (773) 275-6349
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 14D0876728 | Other | IL | CLIA ID MEDICARE |
| 21608069 | Other | IL | BCBS INS ID |
| 363179161 | Other | IL | TAX ID |
| 036042979 | Medicaid | IL | |
| 792111199 | Other | IL | RAILROAD MEDICARE ID |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1159315200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1483660800000",
"number": "1679664163",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1314 CHURCH ST",
"city": "EVANSTON",
"state": "IL",
"postal_code": "602013508",
"telephone_number": "773-275-6349",
"fax_number": "773-275-6385"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1314 CHURCH ST",
"city": "EVANSTON",
"state": "IL",
"postal_code": "602013508",
"telephone_number": "773-275-6349",
"fax_number": "773-275-6385"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FULTZ",
"first_name": "JOHN",
"middle_name": "M",
"name_prefix": "Dr.",
"name_suffix": "II",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-09-27",
"last_updated": "2017-01-06",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "IL",
"license": "036042979",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CLIA ID MEDICARE",
"identifier": "14D0876728",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS INS ID",
"identifier": "21608069",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "TAX ID",
"identifier": "363179161",
"state": "IL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036042979",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE ID",
"identifier": "792111199",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Evanston, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.