1497088025 NPI number — KELLY LOREN MCCULLOUGH PA-C

Table of content: KELLY LOREN MCCULLOUGH PA-C (NPI 1497088025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497088025 NPI number — KELLY LOREN MCCULLOUGH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOUGH
Provider First Name:
KELLY
Provider Middle Name:
LOREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEFFNER
Provider Other First Name:
KELLY
Provider Other Middle Name:
LOREN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497088025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7500 BROOKTREE ROAD
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
WEXFORD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15090-5818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-367-0600
Provider Business Mailing Address Fax Number:
412-367-7079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9104 BABCOCK BLVD
Provider Second Line Business Practice Location Address:
SUITE 2120
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15237-5818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-367-0600
Provider Business Practice Location Address Fax Number:
412-367-7079
Provider Enumeration Date:
09/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  MA051371 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1497088025 . This is a "AETNA BETTER HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "CORVEL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "HIGHMARK MANAGED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "UNITED HEALTHCARE/OPTUM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "AETNA MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "DEVON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "GEISINGER MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "KEYSTONE MANAGED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "HPUOV" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "UPMC COMMERCIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "UNISON OF OH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1490788025 . This is a "GATEWAY MEDICARE ASSURED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "HIGHMARK BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "FLORA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "GATEWAY HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "GREAT WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "UNITED HEALTHCARE/UNISON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1497088025 . This is a "CIGNA BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".




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