Provider Demographics
NPI:1720073521
Name:CULLEN, EDITH M (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:M
Last Name:CULLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 CALIFORNIA RD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-4163
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:2310 CALIFORNIA RD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-4163
Practice Address - Fax:574-262-9650
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061215A208D00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201092890Medicaid
IN223420004Medicare PIN
ILOTH000Medicare UPIN