Basic Information
| Provider Information | |||||||||
| NPI: | 1881808947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | CASEY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1117 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319021117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783448900 | ||||||||
| FaxNumber: | 6786910506 | ||||||||
| Practice Location | |||||||||
| Address1: | 10730 MEDLOCK BRIDGE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608861956 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 045215 | CT | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 78199 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.