Provider Demographics
NPI:1407064652
Name:MCCULLEN, MARY KATE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY KATE
Middle Name:
Last Name:MCCULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 S 9TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6810
Mailing Address - Country:US
Mailing Address - Phone:215-955-1925
Mailing Address - Fax:215-928-3160
Practice Address - Street 1:211 S 9TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6810
Practice Address - Country:US
Practice Address - Phone:215-955-1925
Practice Address - Fax:215-928-3160
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD434015208M00000X, 207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0166065Medicaid
PA102177040Medicaid
PA102177040Medicaid