Healthcare Provider Details

I. General information

NPI: 1740287572
Provider Name (Legal Business Name): WILLIAM MICHAEL MCCULLOUGH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6438 WILMINGTON PIKE SUITE 300
CENTERVILLE OH
45459
US

IV. Provider business mailing address

1 PRESTIGE PL SUITE 550
MIAMISBURG OH
45342-3794
US

V. Phone/Fax

Practice location:
  • Phone: 937-848-4850
  • Fax: 937-848-4858
Mailing address:
  • Phone: 937-762-1305
  • Fax: 937-522-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35-049602
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: