Provider Demographics
NPI:1730371295
Name:MCCULLOUGH, CANDINA RANEE (MD)
Entity type:Individual
Prefix:
First Name:CANDINA
Middle Name:RANEE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MON HEALTH MEDICAL PARK DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1134
Mailing Address - Country:US
Mailing Address - Phone:304-599-6811
Mailing Address - Fax:304-599-7159
Practice Address - Street 1:2000 MON HEALTH MEDICAL PARK DR STE 2100
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-599-6811
Practice Address - Fax:304-599-7159
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-097575207V00000X
WV25595207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050433Medicaid
WV3810022173Medicaid
OHH006482Medicare PIN
OH0050433Medicaid