Provider Demographics
NPI:1497954317
Name:MCCULLOUGH, BRENDAN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:JOHN
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-4748
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDS77772085N0700X, 2085R0202X
IDM-124992085N0700X, 2085R0202X
WAMD601066292085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1613891Medicaid
WA0317438OtherL&I-RADIA REST OF WA
ID1497954317Medicaid
WA0341837OtherL&I-SWEDISH RADIA EDMONDS
WA2018524Medicaid
WA0341836OtherL&I-RADIA KING COUNTY
WA0341845OtherL&I-EVERGREEN RADIA
WA0404021OtherL&I-SEATTLE RADIOLOGY
WAG8919314Medicare PIN
WAP01247741Medicare PIN
WAG8919312Medicare PIN
WAG8919310Medicare PIN