=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891068052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HUGH CHARLES MCCULLOUGH PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2012
-----------------------------------------------------
Last Update Date | 02/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2210 WILBORN AVE
-----------------------------------------------------
City | SOUTH BOSTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24592-1630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-575-5864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7203 QUINCY AVE
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22042-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0110003825
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------