Healthcare Provider Details

I. General information

NPI: 1730306846
Provider Name (Legal Business Name): JOEL EMERY MCCULLOUGH MD, MPH, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOEL EMERY MCCULLOUGH MD

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 CEDAR ST
SAINT PAUL MN
55101
US

IV. Provider business mailing address

555 CEDAR ST
SAINT PAUL MN
55101-2209
US

V. Phone/Fax

Practice location:
  • Phone: 651-266-1222
  • Fax:
Mailing address:
  • Phone: 651-266-1222
  • Fax: 509-324-1507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number63189
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036-104845
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberMD00031369
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: