Healthcare Provider Details

I. General information

NPI: 1275172314
Provider Name (Legal Business Name): MICHAEL PATRICK SCULLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22639 EUCLID AVE
CLEVELAND OH
44117-1622
US

IV. Provider business mailing address

4235 W 212TH ST
FAIRVIEW PARK OH
44126-1105
US

V. Phone/Fax

Practice location:
  • Phone: 216-404-1900
  • Fax:
Mailing address:
  • Phone: 440-773-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1902169
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: