Provider Demographics
NPI:1659366300
Name:SCULLY, THOMAS B (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
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 1:5860 N LA CHOLLA BLVD
Mailing Address - Street 2:#100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3596
Mailing Address - Country:US
Mailing Address - Phone:520-742-7890
Mailing Address - Fax:520-742-7894
Practice Address - Street 1:5860 N LA CHOLLA BLVD
Practice Address - Street 2:#100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3596
Practice Address - Country:US
Practice Address - Phone:520-742-7890
Practice Address - Fax:520-742-7894
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22300207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ164377Medicaid
AZ164377Medicaid
F77437Medicare UPIN