MEDICARE: DR. HEIDI MARIE MCCULLAH O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901004241	MI

General Provider Information

NPI Number	:	1538164728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEIDI MARIE MCCULLAH O.D.

Provider Business Mailing Address
First Line	:	10147 MASTERS RD
Second Line	:
City	:	WALES
State	:	MI
Zip	:	48027-2720
Country	:	US
Telephone Number	:	810-392-2820
Fax Number	:	810-385-5212

Provider Business Practice Location Address
First Line	:	4845 24TH AVE
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3407
Country	:	US
Telephone Number	:	810-358-4114
Fax Number	:	810-385-5212

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	11/15/2008

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