Healthcare Provider Details

I. General information

NPI: 1043207418
Provider Name (Legal Business Name): JOHN MICHAEL MCNULTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 S 8TH ST ST MARIES FAMILY MEDICINE
ST MARIES ID
83861-1813
US

IV. Provider business mailing address

229 S 8TH ST ST MARIES FAMILY MEDICINE
ST MARIES ID
83861-1813
US

V. Phone/Fax

Practice location:
  • Phone: 208-245-2591
  • Fax: 208-245-5246
Mailing address:
  • Phone: 208-245-2591
  • Fax: 208-245-5246

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:
Title or Position:
Credential:
Phone: