MEDICARE: STEVEN G MCCULLOUGH

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	335E00000X	Prosthetic/Orthotic Supplier	101171	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932363751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEVEN G MCCULLOUGH

Provider Business Mailing Address
First Line	:	1110 MEDICAL DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2109
Country	:	US
Telephone Number	:	903-592-5900
Fax Number	:	903-592-6683

Provider Business Practice Location Address
First Line	:	1120 MEDICAL DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-2109
Country	:	US
Telephone Number	:	903-592-5900
Fax Number	:	903-592-6683

Authorized Official
Title or Position	:	OWNER
Name	:	MR. STEVEN GLENN MCCULLOUGH
Credential	:	CERTIFIED ORTHOTIST
Telephone Number	:	903-592-5900

Provider Enumeration Date	:	07/10/2008
Last Update Date	:	07/10/2008

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