1932135704 NPI number — DR. MICHAEL REID MCCULLOUGH DO

Table of content: DR. MICHAEL REID MCCULLOUGH DO (NPI 1932135704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932135704 NPI number — DR. MICHAEL REID MCCULLOUGH DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOUGH
Provider First Name:
MICHAEL
Provider Middle Name:
REID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1932135704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2022
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:
972-988-1588
Provider Business Mailing Address Fax Number:
972-602-0615

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:
972-988-1588
Provider Business Practice Location Address Fax Number:
972-602-0615
Provider Enumeration Date:
06/24/2006

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: 207VX0000X , with the licence number:  H9682 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • 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: "N" .

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

  • Identifier: 033519201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10028878 . This is a "AMERIGROUP ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1275832362 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4250747 . This is a "AETNA ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: G74V . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 033519201 . This is a "TPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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