Provider Demographics
NPI:1093980757
Name:MCCULLOUGH, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
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:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29802-0215
Mailing Address - Country:US
Mailing Address - Phone:803-648-7888
Mailing Address - Fax:803-648-3302
Practice Address - Street 1:410 UNIVERSITY PKWY STE 2500
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6830
Practice Address - Country:US
Practice Address - Phone:803-648-7888
Practice Address - Fax:803-648-3302
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL34041207R00000X
NC148953207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine