Provider Demographics
NPI:1184618233
Name:MCCULLOUGH, GEORGE DAVID (PA)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:DAVID
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 561600
Mailing Address - Street 2:HEALTH FIRST PHYSICIANS INC
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1600
Mailing Address - Country:US
Mailing Address - Phone:321-434-8878
Mailing Address - Fax:321-434-8881
Practice Address - Street 1:1051 S HICKORY ST
Practice Address - Street 2:STE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1962
Practice Address - Country:US
Practice Address - Phone:321-434-8878
Practice Address - Fax:321-434-8881
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA 1918363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S51673Medicare UPIN
FLY5511Medicare ID - Type Unspecified