Provider Demographics
NPI:1659371326
Name:CULLEN, MARC L (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:L
Last Name:CULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:CHILDRENS HOSPITAL OF MICHIGAN
Mailing Address - Street 2:3901 BEAUBIEN BLVD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-831-3220
Mailing Address - Fax:
Practice Address - Street 1:CHILDRENS HOSPITAL OF MICHIGAN
Practice Address - Street 2:3901 BEAUBIEN BLVD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-831-3220
Practice Address - Fax:313-831-3908
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010477282086S0102X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1816457Medicaid
OH2515273OtherBCMH
OH4507190OtherAETNA
MC047728OtherCHAMPUS-CHAMPUS
OH000000521507OtherANTHEM
MC047728OtherCOMMERCIAL-COMMERCIAL NUMBER
OH2515273Medicaid
MI5202214Medicaid
147948OtherGLHP
8161OtherHEALTH PLAN OF MI
OH04672OtherPARAMOUNT
MI4115615Medicaid
MC047728OtherCOMMERCIAL-COMMERCIAL NUMBER
8161OtherHEALTH PLAN OF MI
MC047728OtherCHAMPUS-CHAMPUS
OH04672OtherPARAMOUNT