Provider Demographics
NPI:1003017864
Name:PHILIP K MCCULLOUGH MD SC
Entity Type:Organization
Organization Name:PHILIP K MCCULLOUGH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-695-3680
Mailing Address - Street 1:201 E HURON ST
Mailing Address - Street 2:SUITE 11-100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3197
Mailing Address - Country:US
Mailing Address - Phone:312-695-3680
Mailing Address - Fax:312-926-3709
Practice Address - Street 1:201 E HURON ST
Practice Address - Street 2:SUITE 11-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3197
Practice Address - Country:US
Practice Address - Phone:312-695-3680
Practice Address - Fax:312-926-3709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01635513OtherBCBSIL
IL01635513OtherBCBSIL
IL212233Medicare PIN