Provider Demographics
NPI:1538118849
Name:MCCULLOUGH, BRETT M (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:M
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 N MERIDIAN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-7666
Practice Address - Fax:317-880-0448
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057788A208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200473950Medicaid
IN267030PPMedicare PIN
INP00871808Medicare PIN
INP00297632Medicare PIN
IN165460XXXMedicare PIN
IN200473950Medicaid