Provider Demographics
NPI:1790749042
Name:MCCULLY, MICHAEL C (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:MCCULLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 HEALTH DR SW
Mailing Address - Street 2:SUITE 230
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2093 HEALTH DRIVE SW
Practice Address - Street 2:SUITE 302
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-252-5201
Practice Address - Fax:616-252-5200
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007035207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID97531Medicare UPIN
MI3382454Medicaid
MI1790749042Medicaid
MI0D16078036Medicare PIN
MIN12780010Medicare PIN