MEDICARE: PHILIP K MCCULLOUGH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	036049877	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01635513	OTHER	IL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1396701371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP K MCCULLOUGH MD

Provider Business Mailing Address
First Line	:	676 N SAINT CLAIR ST STE 1510
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2995
Country	:	US
Telephone Number	:	312-695-3680
Fax Number	:	312-695-1959

Provider Business Practice Location Address
First Line	:	676 N SAINT CLAIR ST STE 1510
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2995
Country	:	US
Telephone Number	:	312-695-3680
Fax Number	:	312-926-3709

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	01/21/2021

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