Healthcare Provider Details

I. General information

NPI: 1033284179
Provider Name (Legal Business Name): WAYNE M MCCULLOUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21813 CAPPEL LN
FRANKFORT IL
60423-2275
US

IV. Provider business mailing address

21813 CAPPEL LN
FRANKFORT IL
60423-2275
US

V. Phone/Fax

Practice location:
  • Phone: 978-549-6818
  • Fax: 847-674-0892
Mailing address:
  • Phone: 978-549-6818
  • Fax: 847-674-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1939
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number1939
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number1939
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number1939
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: