Provider Demographics
NPI:1326294158
Name:E THOMAS CULLOM III MD PLLC
Entity Type:Organization
Organization Name:E THOMAS CULLOM III MD PLLC
Other - Org Name:CULLOM, EDWARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CULLOM
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:601-664-1000
Mailing Address - Street 1:1029 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9554
Mailing Address - Country:US
Mailing Address - Phone:601-664-1000
Mailing Address - Fax:601-664-2777
Practice Address - Street 1:1029 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9554
Practice Address - Country:US
Practice Address - Phone:601-664-1000
Practice Address - Fax:601-664-2777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11803207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01409383Medicaid
MS01409383Medicaid