Basic Information
| Provider Information | |||||||||
| NPI: | 1366437972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCULLY | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1509 NW MOCK AVE | ||||||||
| Address2: | |||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640153108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162298187 | ||||||||
| FaxNumber: | 8162291181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1509 NW MOCK AVE | ||||||||
| Address2: | |||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640153108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162298187 | ||||||||
| FaxNumber: | 8162291181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD R4F25 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.