Provider Demographics
NPI:1831183631
Name:MCCULLOUGH, ANDREW RICHARD (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:RICHARD
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:711 TROY - SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:23 HACKETT BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208
Practice Address - Country:US
Practice Address - Phone:518-262-3341
Practice Address - Fax:518-262-6660
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-04-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY194809208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01523642Medicaid
NYB39544Medicare UPIN
NY01523642Medicaid
NYJ400039832Medicare PIN