Basic Information
| Provider Information | |||||||||
| NPI: | 1114983772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCULLY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2716 ASHTON DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284122489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Practice Location | |||||||||
| Address1: | 2716 ASHTON DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284122489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 07/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 28340 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 28340 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8975089 | 05 | NC | MEDICAID | P01048395 | 01 | RR MEDICARE | OTHER |