Healthcare Provider Details

I. General information

NPI: 1699084889
Provider Name (Legal Business Name): J MULLALLY MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 STONE ST SUITE 2
PORT HURON MI
48060-3525
US

IV. Provider business mailing address

1117 STONE ST SUITE 2
PORT HURON MI
48060-3525
US

V. Phone/Fax

Practice location:
  • Phone: 810-966-4540
  • Fax:
Mailing address:
  • Phone: 810-966-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. BETH A NOBLE
Title or Position: OFFICE MANAGER
Credential:
Phone: 810-966-4540