Provider Demographics
NPI:1033284179
Name:MCCULLOUGH, WAYNE M
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:M
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21813 CAPPEL LN
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2275
Mailing Address - Country:US
Mailing Address - Phone:978-549-6818
Mailing Address - Fax:847-674-0892
Practice Address - Street 1:21813 CAPPEL LN
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-2275
Practice Address - Country:US
Practice Address - Phone:978-549-6818
Practice Address - Fax:847-674-0892
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1939213E00000X, 213EP1101X, 213ES0131X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0363037Medicaid
LX5285Medicare PIN
MA0363037Medicaid
4120000001Medicare NSC