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General NPI Number Information
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NPI Number | 1750923538
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Entity Type | Individual
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Provider Name | SAMUEL SCOTT MCCULLOUGH III FNP-C
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Gender | Male
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Dates
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Enumeration Date | 10/12/2019
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Last Update Date | 10/12/2019
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Provider Practice Location Address
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Address Line | 120 FOUNTAINS BLVD # 1000
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City | MADISON
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State | MS
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Zip | 39110-6343
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Country | US
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Telephone | 763-300-0700
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Fax |
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Provider Business Mailing Address
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Address Line | 144 HUBER ST
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City | MADISON
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State | MS
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Zip | 39110-6983
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Country | US
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Telephone | 601-260-9830
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 903614
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License Number State | MS
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