Provider Demographics
NPI:1528003654
Name:MCCULLOUGH, PAUL CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CHARLES
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:53 S LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-1946
Mailing Address - Country:US
Mailing Address - Phone:856-451-4700
Mailing Address - Fax:856-794-7183
Practice Address - Street 1:1200 NORTH HIGH STREET
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-2540
Practice Address - Country:US
Practice Address - Phone:856-451-4700
Practice Address - Fax:856-825-8167
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03740900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B14332Medicare UPIN
010567Medicare ID - Type UnspecifiedGHI
410781Medicare ID - Type UnspecifiedEMPIRE
010560Medicare ID - Type UnspecifiedGHI