Healthcare Provider Details

I. General information

NPI: 1417058314
Provider Name (Legal Business Name): OAK CREEK OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 COMMONS BLVD SUITE 270
BEAVERCREEK OH
45431-3820
US

IV. Provider business mailing address

6438 WILMINGTON PIKE SUITE 300
CENTERVILLE OH
45459-7010
US

V. Phone/Fax

Practice location:
  • Phone: 937-431-0200
  • Fax: 937-431-0488
Mailing address:
  • Phone: 937-848-4850
  • Fax: 937-848-4858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM MICHAEL MCCULLOUGH JR.
Title or Position: SENIOR PHYSICIAN OF PRACTICE
Credential: M.D.
Phone: 937-848-4850