MEDICARE: TIMOTHY JOHN MULRY D.O.

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	282436	NY

General Provider Information

NPI Number	:	1649690868
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY JOHN MULRY D.O.

Provider Business Mailing Address
First Line	:	217 E MAIN ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8407
Country	:	US
Telephone Number	:	631-647-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	217 E MAIN ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8407
Country	:	US
Telephone Number	:	631-647-3800
Fax Number	:

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

Provider Enumeration Date	:	04/27/2014
Last Update Date	:	08/10/2020

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