=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851410138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN A MCCULLOUGH NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 11/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 S 11TH ST SUITE 6270
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-955-4912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2141 SAINT ALBANS ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19146-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-431-4887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP009159
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------