MEDICARE: PETER AYLWARD SCULLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	5585	NV

General Provider Information

NPI Number	:	1134136815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER AYLWARD SCULLY MD

Provider Business Mailing Address
First Line	:	4230 BURNHAM AVENUE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119
Country	:	US
Telephone Number	:	702-733-7866
Fax Number	:	702-733-8862

Provider Business Practice Location Address
First Line	:	4230 BURNHAM AVENUE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119
Country	:	US
Telephone Number	:	702-733-7866
Fax Number	:	702-792-1319

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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