Provider Demographics
NPI:1811375983
Name:TULLY, ANDREW (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:TULLY
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:PO BOX 64226
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4226
Mailing Address - Country:US
Mailing Address - Phone:667-214-1734
Mailing Address - Fax:410-706-6976
Practice Address - Street 1:16 S EUTAW ST FL 1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1606
Practice Address - Country:US
Practice Address - Phone:667-214-1718
Practice Address - Fax:410-328-6343
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 390200000X
MDD0097643208600000X
MDD97643208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program