Individual
WILLIAM G NULTY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
ONE ILLINI DR, MEDICAL SERVICE PLAN, PEORIA, IL 61605
(309) 671-8503
Mailing address
1 ILLINI DR, PEORIA, IL 61605-2576
(309) 671-8503
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
036085410
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036085410
—
IL
01
—
07215036
BCBS
IL
01
—
IL01DC
JOHN DEERE
IL
Enumeration date
03/15/2006
Last updated
07/09/2007
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