Provider Demographics
NPI:1013226455
Name:MCCULLOUGH, GEORGE W (RN)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N. BLOOMFIELD RD.
Mailing Address - Street 2:#15
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1008
Mailing Address - Country:US
Mailing Address - Phone:731-343-4543
Mailing Address - Fax:
Practice Address - Street 1:125 N. BLOOMFIELD RD.
Practice Address - Street 2:#15
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1008
Practice Address - Country:US
Practice Address - Phone:731-343-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330607163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse