NPIMap

Individual provider Active NPI

Brent Fuller

  • Internal Medicine Physician
  • Royal Oak, MI
National Provider Identifier
1871552646
Registry record updated Oct 5, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
4301070157 Issued in MI
Practice address
3535 W 13 Mile Rd Ste LL
Royal Oak, MI 48073-6770
Phone
(248) 551-3000
NPI assigned
Mar 21, 2006
Last updated
Oct 5, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 5, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X 4301070157 MI
Internal Medicine Physician 207R00000X 4301070157 MI Primary

Addresses

Primary practice location

3535 W 13 Mile Rd Ste LL
Royal Oak, MI 48073-6770

Mailing address

26901 Beaumont Blvd Ste 3D
Southfield, MI 48033-3849

Other identifiers 2

IdentifierTypeStateIssuer
4800002MedicaidMI
110F376980OtherMIBCBSM

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address bfuller9560@direct.beaumont.edu

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040126000341 MI Practitioner - Internal MedicinePractitioner - Pediatric Medicine 7315849718 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Internal MedicineAlso: Pediatric Medicine
Education
Wayne State University School of Medicine, 1997
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Oakwood Ambulatory LLCGroup PAC ID 1850282914, 271 clinicians

Practice addresses (Care Compare)

201 3Rd St
Suite 200
Belleville, MI 48111-2605
Phone (734) 697-9065

3535 W 13 Mile Rd
Royal Oak, MI 48073-6770
Phone (248) 551-3000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
4301070157MIMDInternal Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Michigan Adult & Child Medicine Internal Medicine CurrentSince Jul 1, 2007 Accepting new patients
William Beaumont Hospital Past Accepting new patients

Locations

11885 E 12 Mile Rd
Ste 100A
Warren, MI 48093
Phone (586) 576-1615

8545 Common Rd
Ste 200
Warren, MI 48093
Phone (586) 751-0732

Interoperability endpoints

  • Direct secure messaging: bfuller@macm.gwaydirect.com
  • Direct secure messaging: bfuller2202@epic00.corewelldirect.org
  • Direct secure messaging: bfuller9560@direct.beaumont.edu

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 12

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1142899200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1633392000000",
    "number": "1871552646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "26901 BEAUMONT BLVD STE 3D",
            "city": "SOUTHFIELD",
            "state": "MI",
            "postal_code": "480333849"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3535 W 13 MILE RD STE LL",
            "city": "ROYAL OAK",
            "state": "MI",
            "postal_code": "480736770",
            "telephone_number": "248-551-3000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULLER",
        "first_name": "BRENT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-21",
        "last_updated": "2021-10-05",
        "certification_date": "2021-10-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "MI",
            "license": "4301070157",
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MI",
            "license": "4301070157",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4800002",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBSM",
            "identifier": "110F376980",
            "state": "MI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "bfuller9560@direct.beaumont.edu",
            "affiliation": "N",
            "address_1": "3535 W 13 Mile Rd Ste Ll",
            "city": "Royal Oak",
            "state": "MI",
            "country_code": "US",
            "postal_code": "480736770",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Royal Oak, MI

Sources for this page

Verify at the official NPI Registry.