MEDICARE: DR. MICHAEL JOHN KILCULLEN 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	2080P0006X	Developmental - Behavioral Pediatrics Physician	6140	NH
2	2080P0006X	Developmental - Behavioral Pediatrics Physician	6370	VT

General Provider Information

NPI Number	:	1972514081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JOHN KILCULLEN M.D.

Provider Business Mailing Address
First Line	:	32 PLEASANT ST
Second Line	:
City	:	WOODSTOCK
State	:	VT
Zip	:	05091-1122
Country	:	US
Telephone Number	:	802-457-3053
Fax Number	:

Provider Business Practice Location Address
First Line	:	32 PLEASANT ST
Second Line	:
City	:	WOODSTOCK
State	:	VT
Zip	:	05091-1122
Country	:	US
Telephone Number	:	802-457-3053
Fax Number	:

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	10/28/2008

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