Provider Demographics
NPI:1518058148
Name:MCCULLEY, DORIS JEAN (MD,MBA)
Entity Type:Individual
Prefix:DR
First Name:DORIS
Middle Name:JEAN
Last Name:MCCULLEY
Suffix:
Gender:F
Credentials:MD,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 MACFARLANE CRES
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1428
Mailing Address - Country:US
Mailing Address - Phone:708-798-3091
Mailing Address - Fax:708-798-4192
Practice Address - Street 1:2930 MAC FARLANE CRES.
Practice Address - Street 2:2800 WEST 87TH STREET
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652
Practice Address - Country:US
Practice Address - Phone:312-829-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD1476Medicare UPIN