Provider Demographics
NPI:1568444552
Name:DOM, PATRICK MCCULLOUGH (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:MCCULLOUGH
Last Name:DOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1325 MOUNT HERMON RD
Mailing Address - Street 2:SUITE 14B
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5259
Mailing Address - Country:US
Mailing Address - Phone:410-742-4401
Mailing Address - Fax:410-742-4798
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-543-7375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062873207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD407816100Medicaid
MDP00222914OtherRAILROAD MEDICARE
MDP00222914OtherRAILROAD MEDICARE
MDS504L546Medicare PIN