Provider Demographics
NPI:1407840812
Name:MCCULLOUGH, MARY ELLEN K (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:K
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5053 WOOSTER RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45226-2326
Mailing Address - Country:US
Mailing Address - Phone:513-751-2145
Mailing Address - Fax:513-751-2138
Practice Address - Street 1:5525 MARIE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-3200
Practice Address - Country:US
Practice Address - Phone:513-751-2273
Practice Address - Fax:513-574-7062
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069652207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200499880Medicaid
KY64089188Medicaid
OH2048733Medicaid
G64218Medicare UPIN
KY64089188Medicaid