MEDICARE: DR. MICHAEL PULLA DPM

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	390200000X	Student in an Organized Health Care Education/Training Program	135000848	IL
2	213E00000X	Podiatrist	016.005658	IL

General Provider Information

NPI Number	:	1568877819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL PULLA DPM

Provider Business Mailing Address
First Line	:	1539 FARMSIDE LN
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60490-4960
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1234 WELLS
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612
Country	:	US
Telephone Number	:	123-456-7890
Fax Number	:

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

Provider Enumeration Date	:	06/25/2014
Last Update Date	:	12/01/2017

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