Provider Demographics
NPI:1386963254
Name:MCCULLOCH ORTHOPAEDIC SURGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:MCCULLOCH ORTHOPAEDIC SURGICAL SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-275-1919
Mailing Address - Street 1:520 FRANKLIN AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-5815
Mailing Address - Country:US
Mailing Address - Phone:212-588-1919
Mailing Address - Fax:212-588-1896
Practice Address - Street 1:12510 QUEENS BLVD STE 9
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415
Practice Address - Country:US
Practice Address - Phone:212-588-1919
Practice Address - Fax:877-992-0798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02880679Medicaid
NY02880678Medicaid
NY02880678Medicaid