Provider Demographics
NPI:1639167141
Name:MCCULLOCH, HARLAN A (MD)
Entity Type:Individual
Prefix:
First Name:HARLAN
Middle Name:A
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36351
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28236-6351
Mailing Address - Country:US
Mailing Address - Phone:704-377-5772
Mailing Address - Fax:704-377-3389
Practice Address - Street 1:8800 N TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3300
Practice Address - Country:US
Practice Address - Phone:704-548-5663
Practice Address - Fax:704-548-6997
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29626207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8952588Medicaid
SCN29626Medicaid
NC208668GMedicare PIN
NC8952588Medicaid