1710999123 NPI number — HEATHER C MCCULLOUGH MD

Table of content: HEATHER C MCCULLOUGH MD (NPI 1710999123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710999123 NPI number — HEATHER C MCCULLOUGH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLOUGH
Provider First Name:
HEATHER
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710999123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3434 HANCOCK BRIDGE PKWY
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
NORTH FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33903-7099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:
239-599-2612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 TAMIAMI TRL S
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34285-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-488-7716
Provider Business Practice Location Address Fax Number:
941-488-0511
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME59667 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12169 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 055158900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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