Healthcare Provider Details

I. General information

NPI: 1003017864
Provider Name (Legal Business Name): PHILIP K MCCULLOUGH MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E HURON ST SUITE 11-100
CHICAGO IL
60611-3197
US

IV. Provider business mailing address

201 E HURON ST SUITE 11-100
CHICAGO IL
60611-3197
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-3680
  • Fax: 312-926-3709
Mailing address:
  • Phone: 312-695-3680
  • Fax: 312-926-3709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: PHILIP K MCCULLOUGH
Title or Position: PRESIDENT
Credential: MD
Phone: 312-695-3680