Provider Demographics
NPI:1396157392
Name:MCCULLOUGH, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-2225
Mailing Address - Country:US
Mailing Address - Phone:856-829-0232
Mailing Address - Fax:
Practice Address - Street 1:895 WESTFIELD RD
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-2123
Practice Address - Country:US
Practice Address - Phone:856-914-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-24
Last Update Date:2014-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09019000172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker