MEDICARE: DR. LAURA JILL TULLY 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	207Y00000X	Otolaryngology Physician		GA
2	207Y00000X	Otolaryngology Physician	Q7611	TX
3	207Y00000X	Otolaryngology Physician	CDR.0005758	CO
4	207Y00000X	Otolaryngology Physician	35.132034	OH
5	207Y00000X	Otolaryngology Physician	C3349	KY

General Provider Information

NPI Number	:	1871883066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA JILL TULLY MD

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD
Second Line	:	BUILDING B, 3RD FLOOR
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-991-3188
Fax Number	:	937-223-9811

Provider Business Practice Location Address
First Line	:	31 S STANFIELD RD STE 304
Second Line	:
City	:	TROY
State	:	OH
Zip	:	45373-2334
Country	:	US
Telephone Number	:	937-440-7872
Fax Number	:	937-440-7874

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

Provider Enumeration Date	:	04/09/2011
Last Update Date	:	12/03/2025

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