Provider Demographics
NPI:1720170632
Name:SCULLY, NIALL M (MD)
Entity Type:Individual
Prefix:DR
First Name:NIALL
Middle Name:M
Last Name:SCULLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:67-1123 MAMALAHOA HWY
Mailing Address - Street 2:SUSITE 128
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8451
Mailing Address - Country:US
Mailing Address - Phone:808-885-9170
Mailing Address - Fax:808-885-1787
Practice Address - Street 1:67-1123 MAMALAHOA HWY
Practice Address - Street 2:SUSITE 128
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8451
Practice Address - Country:US
Practice Address - Phone:808-885-9170
Practice Address - Fax:808-885-1787
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HI849208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI02559601Medicaid
HI0B0028544OtherHMSA
HI02559601Medicaid
HI0000BFCMVMedicare ID - Type Unspecified