Provider Demographics
NPI:1750395984
Name:TULLY, KATHLEEN M (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:TULLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:24 SOMERS CT
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-3007
Mailing Address - Country:US
Mailing Address - Phone:410-952-3346
Mailing Address - Fax:
Practice Address - Street 1:16918 YORK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MONKTON
Practice Address - State:MD
Practice Address - Zip Code:21111-1022
Practice Address - Country:US
Practice Address - Phone:410-357-5559
Practice Address - Fax:410-343-3008
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0029301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC49110Medicare UPIN