MEDICARE: DR. STEPHEN J CHIULLI PH.D.

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	103G00000X	Clinical Neuropsychologist	500	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NM00NB60	OTHER	NM	BLUE CROSS
2	7395	OTHER	NM	LOVELACE HEALTH PLAN
3	7395	OTHER	NM	CIGNA

General Provider Information

NPI Number	:	1245363878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN J CHIULLI PH.D.

Provider Business Mailing Address
First Line	:	2201 SAN PEDRO DR NE
Second Line	:	BUILDING 1, SUITE 215
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4133
Country	:	US
Telephone Number	:	505-889-0426
Fax Number	:	505-883-7304

Provider Business Practice Location Address
First Line	:	2201 SAN PEDRO DR NE
Second Line	:	BUILDING 1, SUITE 215
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4133
Country	:	US
Telephone Number	:	505-889-0426
Fax Number	:	505-883-7304

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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