MEDICARE: MICHAEL PATRICK SCULLY

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	390200000X	Student in an Organized Health Care Education/Training Program	1902169	OH

General Provider Information

NPI Number	:	1275172314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL PATRICK SCULLY

Provider Business Mailing Address
First Line	:	4235 W 212TH ST
Second Line	:
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-1105
Country	:	US
Telephone Number	:	440-773-6803
Fax Number	:

Provider Business Practice Location Address
First Line	:	22639 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44117-1622
Country	:	US
Telephone Number	:	216-404-1900
Fax Number	:

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

Provider Enumeration Date	:	01/06/2020
Last Update Date	:	01/06/2020

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