Provider Demographics
NPI:1649211897
Name:MCCULLOUGH, PATRICK J (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:MCCULLOUGH
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 1:1101 SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45237-2621
Mailing Address - Country:US
Mailing Address - Phone:513-948-3600
Mailing Address - Fax:513-948-8631
Practice Address - Street 1:1101 SUMMIT RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-2621
Practice Address - Country:US
Practice Address - Phone:513-948-3600
Practice Address - Fax:513-948-8631
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069168207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64956493Medicaid
OH0382321Medicaid
OHG42320Medicare UPIN
OHMC0815798Medicare ID - Type Unspecified