Healthcare Provider Details

I. General information

NPI: 1639872021
Provider Name (Legal Business Name): ELISE MCNULTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 ORLEANS ST
BALTIMORE MD
21287-0010
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
BALTIMORE MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 667-284-1072
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberD0106939
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number9314
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: