Provider Demographics
NPI:1346223468
Name:MCCULLOUGH, RUSSELL WADE (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WADE
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3601 NE RALPH POWELL RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2357
Mailing Address - Country:US
Mailing Address - Phone:816-251-1200
Mailing Address - Fax:816-251-1280
Practice Address - Street 1:3601 NE RALPH POWELL RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-2357
Practice Address - Country:US
Practice Address - Phone:816-251-1200
Practice Address - Fax:816-251-1280
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001006773207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209336205Medicaid
I13877Medicare UPIN