Healthcare Provider Details

I. General information

NPI: 1720334493
Provider Name (Legal Business Name): PETER THOMAS SCULLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
SAINT PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

501 6TH AVE S STE 1.134
SAINT PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-4343
  • Fax:
Mailing address:
  • Phone: 727-767-8346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberS1704
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberS1704
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberS1704
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME161982
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: