Provider Demographics
NPI:1295858330
Name:MCCULLEY, HENRY PAUL
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:PAUL
Last Name:MCCULLEY
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 1406
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37371-1406
Mailing Address - Country:US
Mailing Address - Phone:423-744-7449
Mailing Address - Fax:423-744-8574
Practice Address - Street 1:740 TELL ST
Practice Address - Street 2:STE 500
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303
Practice Address - Country:US
Practice Address - Phone:423-744-7449
Practice Address - Fax:423-744-8574
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000431213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3352085Medicaid
U46917Medicare UPIN
TN3352085Medicaid
TN3352085Medicare ID - Type Unspecified