Basic Information
| Provider Information | |||||||||
| NPI: | 1407840812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | MARY ELLEN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5053 WOOSTER RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452262326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137512145 | ||||||||
| FaxNumber: | 5137512138 | ||||||||
| Practice Location | |||||||||
| Address1: | 5525 MARIE AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452483200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137512273 | ||||||||
| FaxNumber: | 5135747062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 35069652 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 200499880 | 05 | IN | MEDICAID | 64089188 | 05 | KY | MEDICAID | 2048733 | 05 | OH | MEDICAID |