Provider Demographics
NPI:1629015839
Name:MCNULTY, BRUCE W (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5940
Mailing Address - Street 2:DEPT 20-1070
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-5940
Mailing Address - Country:US
Mailing Address - Phone:630-734-0200
Mailing Address - Fax:630-734-1560
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:630-734-1560
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-082932207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082932Medicaid
A66492Medicare UPIN