Healthcare Provider Details

I. General information

NPI: 1194996470
Provider Name (Legal Business Name): JOHN M MCNULTY MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 MCKINLEY AVE
KELLOGG ID
83837-2693
US

IV. Provider business mailing address

862 CHERRY CREEK RD
ST MARIES ID
83861-9329
US

V. Phone/Fax

Practice location:
  • Phone: 208-783-1267
  • Fax:
Mailing address:
  • Phone: 208-245-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM7646
License Number StateID

VIII. Authorized Official

Name: DR. JOHN M MCNULTY
Title or Position: SELF
Credential: MD
Phone: 208-784-7017