Provider Demographics
NPI:1346200680
Name:SCULLY, DENNIS M (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
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 1:3822 SCHAPER AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-3360
Mailing Address - Country:US
Mailing Address - Phone:814-864-0943
Mailing Address - Fax:814-864-1160
Practice Address - Street 1:3822 SCHAPER AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-3360
Practice Address - Country:US
Practice Address - Phone:814-868-0943
Practice Address - Fax:814-866-1160
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017266E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000884452Medicaid
PA0008844520002Medicaid
PAB39068Medicare UPIN
PA0008844520002Medicaid
PA140794Medicare ID - Type Unspecified