MEDICARE: DR. ANDREW J MULLALLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01074259A	IN

General Provider Information

NPI Number	:	1164860086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW J MULLALLY MD

Provider Business Mailing Address
First Line	:	10050 AUBURN PARK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2389
Country	:	US
Telephone Number	:	260-432-6459
Fax Number	:	260-240-5284

Provider Business Practice Location Address
First Line	:	10050 AUBURN PARK DR
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2389
Country	:	US
Telephone Number	:	260-432-6459
Fax Number	:	260-240-5284

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	04/20/2017

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