Healthcare Provider Details

I. General information

NPI: 1750923538
Provider Name (Legal Business Name): SAMUEL SCOTT MCCULLOUGH III FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2019
Last Update Date: 03/15/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 HAZELTON CV
GLUCKSTADT MS
39110-6961
US

IV. Provider business mailing address

106 EAGLE CV
MADISON MS
39110-6629
US

V. Phone/Fax

Practice location:
  • Phone: 601-633-9017
  • Fax:
Mailing address:
  • Phone: 601-260-9830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number903614
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: