Provider Demographics
NPI:1285692608
Name:SCULLY, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SCULLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 DUNN RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-7928
Mailing Address - Country:US
Mailing Address - Phone:314-315-9913
Mailing Address - Fax:314-872-8069
Practice Address - Street 1:450 N NEW BALLAS RD
Practice Address - Street 2:SUITE 150N
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-315-9914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9882208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00195684OtherPALMETTO RR MEDICARE
MOP00195684OtherPALMETTO RR MEDICARE
MOA11559Medicare UPIN