Healthcare Provider Details

I. General information

NPI: 1386963254
Provider Name (Legal Business Name): MCCULLOCH ORTHOPAEDIC SURGICAL SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 QUEENS BLVD STE 9
KEW GARDENS NY
11415-1522
US

IV. Provider business mailing address

520 FRANKLIN AVE STE 212
GARDEN CITY NY
11530-5815
US

V. Phone/Fax

Practice location:
  • Phone: 212-355-5555
  • Fax: 877-992-0798
Mailing address:
  • Phone: 212-355-5555
  • Fax: 877-992-0798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREW MCCULLOCH
Title or Position: COO
Credential:
Phone: 734-645-3899