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NPI Code Detail

MEDICARE: KELLY PUCILLO MD

MEDICARE: KELLY PUCILLO 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
1207Q00000XFamily Medicine Physician49596-020WI

General Provider Information

NPI Number : 1548200595
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY PUCILLO MD
Provider Business Mailing Address
First Line : 710 RIVERSIDE DR
Second Line :
City : WAUPACA
State : WI
Zip : 54981-1941
Country : US
Telephone Number : 608-829-5247
Fax Number :
Provider Business Practice Location Address
First Line : 710 RIVERSIDE DR
Second Line :
City : WAUPACA
State : WI
Zip : 54981-1941
Country : US
Telephone Number : 715-258-1160
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/07/2006
Last Update Date : 03/15/2012

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