Healthcare Provider Details

I. General information

NPI: 1942641675
Provider Name (Legal Business Name): MCCULLOUGH MEDICAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 WELLNESS LN
NEW PORT RICHEY FL
34655-5357
US

IV. Provider business mailing address

1814 WELLNESS LN
NEW PORT RICHEY FL
34655-5357
US

V. Phone/Fax

Practice location:
  • Phone: 727-645-4541
  • Fax:
Mailing address:
  • Phone: 727-645-4541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberME107055
License Number StateFL

VIII. Authorized Official

Name: DR. MONA MCCULLOUGH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 727-645-4541