Provider Demographics
NPI:1629068655
Name:MCCULLOUGH, GENE P (RN,NP)
Entity Type:Individual
Prefix:MR
First Name:GENE
Middle Name:P
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:RN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WILLOUGHBY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-3726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 AMSTERDAM AVE
Practice Address - Street 2:ST.LUKE'S/ROOSEVELT HOSPITAL PSYCHIATRY DEPARTMENT
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1737
Practice Address - Country:US
Practice Address - Phone:917-596-7336
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400071-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02136450Medicaid
NY02136450Medicaid