Provider Demographics
NPI:1740591411
Name:MCCULLOUGH, PHILLIP (DPT)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 43RD AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:5700 UNIVERSITY AVE STE 222
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8276
Practice Address - Country:US
Practice Address - Phone:515-221-1621
Practice Address - Fax:515-221-1626
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist