Provider Demographics
NPI:1194996470
Name:JOHN M MCNULTY MD PC
Entity type:Organization
Organization Name:JOHN M MCNULTY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-784-7017
Mailing Address - Street 1:862 CHERRY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-9329
Mailing Address - Country:US
Mailing Address - Phone:208-245-9233
Mailing Address - Fax:
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2693
Practice Address - Country:US
Practice Address - Phone:208-783-1267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7646207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE79014Medicare UPIN