Basic Information
Provider Information | |||||||||
NPI: | 1669561429 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OAK CREEK OBGYN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6438 WILMINGTON PIKE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | CENTERVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 454597010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9378484850 | ||||||||
FaxNumber: | 9378484858 | ||||||||
Practice Location | |||||||||
Address1: | 10 REMICK BLVD | ||||||||
Address2: |   | ||||||||
City: | SPRINGBORO | ||||||||
State: | OH | ||||||||
PostalCode: | 450669168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9378862705 | ||||||||
FaxNumber: | 9378862713 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 08/12/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCULLOUGH | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR PHYSICIAN OF PRACTICE | ||||||||
AuthorizedOfficialTelephone: | 9378484850 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.