Provider Demographics
NPI:1558333062
Name:MCCULLOUGH, JOHN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SCOTT
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 30309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-0309
Mailing Address - Country:US
Mailing Address - Phone:843-554-9300
Mailing Address - Fax:843-566-8780
Practice Address - Street 1:1771 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4990
Practice Address - Country:US
Practice Address - Phone:931-551-1939
Practice Address - Fax:931-221-2236
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34439207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3858460Medicaid
TN3858460Medicaid
TN3858464Medicare PIN