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General NPI Number Information
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NPI Number | 1932117744
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Entity Type | Individual
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Provider Name | KATHLEEN I MCCULLOUGH MD
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Gender | Female
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 05/31/2011
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Provider Practice Location Address
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Address Line | 133 BROOKLINE AVE
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City | BOSTON
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State | MA
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Zip | 02215-3904
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Country | US
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Telephone | 617-421-6050
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Fax | 617-421-6083
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Provider Business Mailing Address
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Address Line | 147 MILK ST PROVIDER ENROLLMENT 9TH FLOOR
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City | BOSTON
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State | MA
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Zip | 02109-4806
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Country | US
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Telephone | 617-421-2508
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Fax | 617-421-3487
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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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 79413
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License Number State | MA
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