Provider Demographics
NPI:1730306846
Name:MCCULLOUGH, JOEL EMERY (MD, MPH, MS)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:EMERY
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD, MPH, MS
Other - Prefix:
Other - First Name:JOEL
Other - Middle Name:EMERY
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:555 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2209
Mailing Address - Country:US
Mailing Address - Phone:651-266-1222
Mailing Address - Fax:509-324-1507
Practice Address - Street 1:555 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-266-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN631892083P0901X
IL036-1048452083P0901X
WAMD000313692083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F04416Medicare UPIN