Provider Demographics
NPI:1164403598
Name:CULLEN, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:CULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4326 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6867
Mailing Address - Country:US
Mailing Address - Phone:309-797-6611
Mailing Address - Fax:309-797-7181
Practice Address - Street 1:4326 7TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6867
Practice Address - Country:US
Practice Address - Phone:309-797-6611
Practice Address - Fax:309-797-7181
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360789982084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078998Medicaid
IA094843OtherMEDICAID
IL08100424OtherBCBS IL
D24712Medicare UPIN
IL036078998Medicaid