Healthcare Provider Details

I. General information

NPI: 1851121644
Provider Name (Legal Business Name): BRANDON MCCULLOUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 N MAIN
CEDAR SPRINGS MI
49319-8041
US

IV. Provider business mailing address

3134 PLAZA DR NE APT A16
GRAND RAPIDS MI
49525-2942
US

V. Phone/Fax

Practice location:
  • Phone: 616-696-2020
  • Fax:
Mailing address:
  • Phone: 616-322-8463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: