1235378449 NPI number — MRS. KELLY S MC CORMICK P.T.

Table of content: MRS. KELLY S MC CORMICK P.T. (NPI 1235378449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235378449 NPI number — MRS. KELLY S MC CORMICK P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MC CORMICK
Provider First Name:
KELLY
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROOKS
Provider Other First Name:
KELLY
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235378449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1719 CLAWSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62002-4702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-462-1133
Provider Business Mailing Address Fax Number:
618-462-3736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1719 CLAWSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-462-1133
Provider Business Practice Location Address Fax Number:
618-462-3736
Provider Enumeration Date:
02/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  070016904 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 070016904 . This is a "LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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