Healthcare Provider Details

I. General information

NPI: 1356387609
Provider Name (Legal Business Name): MARC C MCCULLOCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E PALMER RD
BELLEFONTAINE OH
43311-2281
US

IV. Provider business mailing address

266 MULADORE DR
POWELL OH
43065-9388
US

V. Phone/Fax

Practice location:
  • Phone: 937-592-4015
  • Fax:
Mailing address:
  • Phone: 614-496-1355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35052132
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: