MEDICARE: DR. MARYK CULLEN MARYK CULLEN, M.D.

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	174400000X	Specialist	106422	MO

General Provider Information

NPI Number	:	1902011703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYK CULLEN MARYK CULLEN, M.D.

Provider Business Mailing Address
First Line	:	6315 PERSHING AVE
Second Line	:
City	:	UNIVERSITY CITY
State	:	MO
Zip	:	63130-4704
Country	:	US
Telephone Number	:	314-721-8267
Fax Number	:

Provider Business Practice Location Address
First Line	:	2431 N GRAND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63106-1018
Country	:	US
Telephone Number	:	314-652-9233
Fax Number	:	314-533-5430

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

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	07/09/2007

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