Healthcare Provider Details

I. General information

NPI: 1932321346
Provider Name (Legal Business Name): PAUL MCCULLOUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 E MEDICAL CENTER DR
ST GEORGE UT
84790-2123
US

IV. Provider business mailing address

PO BOX 3570
SALT LAKE CITY UT
84110-3570
US

V. Phone/Fax

Practice location:
  • Phone: 801-727-2056
  • Fax: 770-701-6675
Mailing address:
  • Phone: 801-727-2056
  • Fax: 770-701-6675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD153282
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMT188120
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number12078813-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500636545
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: