Provider Demographics
NPI:1750383790
Name:MCCULLOCH, THOMAS HARVEY (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:HARVEY
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N SECTION ST
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-2613
Mailing Address - Country:US
Mailing Address - Phone:251-990-8860
Mailing Address - Fax:251-990-3401
Practice Address - Street 1:405 N SECTION ST
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2613
Practice Address - Country:US
Practice Address - Phone:251-990-8860
Practice Address - Fax:251-990-3401
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9298207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51540979OtherBCBS
AL9910667Medicaid
ALP00457381OtherRAILROAD MCARE
AL1750383790OtherNPI
AL9910667Medicaid