Healthcare Provider Details

I. General information

NPI: 1063518975
Provider Name (Legal Business Name): KEVIN MCCULLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 COURT ST
PLATTSBURGH NY
12901-2733
US

IV. Provider business mailing address

154 PROSPECT AVE
PLATTSBURGH NY
12901-1302
US

V. Phone/Fax

Practice location:
  • Phone: 518-562-1080
  • Fax: 518-562-3316
Mailing address:
  • Phone: 518-563-5440
  • Fax: 518-563-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number164868
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: