Provider Demographics
NPI:1982607172
Name:CULLIS, CASS M (MD)
Entity Type:Individual
Prefix:
First Name:CASS
Middle Name:M
Last Name:CULLIS
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 1:3006 N COUNTY ROAD 25A
Mailing Address - Street 2:STE 104
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1373
Mailing Address - Country:US
Mailing Address - Phone:937-335-3518
Mailing Address - Fax:937-332-6857
Practice Address - Street 1:3006 N COUNTY ROAD 25A
Practice Address - Street 2:STE 104
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1373
Practice Address - Country:US
Practice Address - Phone:937-335-3518
Practice Address - Fax:937-332-6857
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.041154207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0472939Medicaid
OH0472939Medicaid
OH0502992Medicare PIN
OHCU0502991Medicare PIN