=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518030311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MULLALLY HOLDINGS PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 09/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11515 W EMERALD OAKS DR
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34428-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-794-3862
-----------------------------------------------------
Fax | 352-794-3844
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11515 W EMERALD OAKS DR
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34428-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-794-3862
-----------------------------------------------------
Fax | 352-794-3844
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRIAN ANDREW MULLALLY SR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 352-794-3862
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME104121
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------