MEDICARE: DR. KEANE EMILE MCCULLUM 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	207V00000X	Obstetrics & Gynecology Physician	20964	HI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NAD000	OTHER		MEDICARE UPIN

General Provider Information

NPI Number	:	1841793510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEANE EMILE MCCULLUM MD

Provider Business Mailing Address
First Line	:	1601 E BROADWAY STE 100
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-5821
Country	:	US
Telephone Number	:	573-443-8796
Fax Number	:	573-443-0737

Provider Business Practice Location Address
First Line	:	1601 E BROADWAY STE 100
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65201-5821
Country	:	US
Telephone Number	:	573-443-8796
Fax Number	:	573-443-8796

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

Provider Enumeration Date	:	03/08/2018
Last Update Date	:	12/17/2025

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