1104959428 NPI number — TARA LINETTE MCCORMICK OTD, OTRL

Table of content: TARA LINETTE MCCORMICK OTD, OTRL (NPI 1104959428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104959428 NPI number — TARA LINETTE MCCORMICK OTD, OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCORMICK
Provider First Name:
TARA
Provider Middle Name:
LINETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTD, OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104959428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4990 KISER ISLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRELL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28682-9773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-243-2433
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1178B RIVER HWY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-9064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-243-2433
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/14/2007

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: 225XP0200X , with the licence number:  5915 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 2096 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OT0174 . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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