1275832362 NPI number — MICHAEL R. MCCULLOUGH, D.O., P.A.

Table of content: (NPI 1275832362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275832362 NPI number — MICHAEL R. MCCULLOUGH, D.O., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL R. MCCULLOUGH, D.O., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275832362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
643 S GREAT SOUTHWEST PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GRAND PRAIRIE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75051-1056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-602-0615
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
643 S GREAT SOUTHWEST PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GRAND PRAIRIE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75051-1056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-602-0615
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MCCULLOUGH
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
972-988-1588

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  H9682 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 033519201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com