Basic Information
| Provider Information | |||||||||
| NPI: | 1114124690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOCH | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631374 | ||||||||
| Practice Location | |||||||||
| Address1: | 19020 33RD AVE W STE 210 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980364748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255631500 | ||||||||
| FaxNumber: | 4255631501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101248086 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | M-12463 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60424508 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0325621 | 01 | WA | LNI-SWEDISH RADIA EDMONDS | OTHER | 0385244 | 01 | WA | LNI-SOUTH SOUND | OTHER | 0325622 | 01 | WA | LNIEVERGREEN RADIA | OTHER | 1114124690 | 05 | WA | MEDICAID | 2035053 | 05 | WA | MEDICAID | 0325620 | 01 | WA | LNI-RADIA REST OF WA COUNTIES | OTHER | 0327385 | 01 | WA | LNI-RADIA KING COUNTY | OTHER | 1114124690 | 05 | ID | MEDICAID |