Healthcare Provider Details

I. General information

NPI: 1740964303
Provider Name (Legal Business Name): MAIREIGH MCCULLOUGH MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAIREIGH NICHOLAS

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF INTERNAL MEDICINE 3601 4TH ST
LUBBOCK TX
79430-0001
US

IV. Provider business mailing address

DEPARTMENT OF INTERNAL MEDICINE 3601 4TH ST
LUBBOCK TX
79430-0001
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-3155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10083594
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: