Provider Demographics
NPI:1326093139
Name:MCCORMACK, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12715 WARWICK BLVD
Mailing Address - Street 2:SUITE V
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1800
Mailing Address - Country:US
Mailing Address - Phone:757-930-0139
Mailing Address - Fax:757-930-4132
Practice Address - Street 1:12715 WARWICK BLVD
Practice Address - Street 2:SUITE V
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1800
Practice Address - Country:US
Practice Address - Phone:757-930-0139
Practice Address - Fax:757-930-4132
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA186930 20061744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9112979Medicaid
VA1096040001Medicare ID - Type UnspecifiedPROVIDER NUMBER