Provider Demographics
NPI:1497154967
Name:MCCORMICK, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 SOCKANOSSET CROSSROAD
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920
Mailing Address - Country:US
Mailing Address - Phone:401-944-7574
Mailing Address - Fax:401-944-7602
Practice Address - Street 1:51 SOCKANOSSET CROSS RD
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-5536
Practice Address - Country:US
Practice Address - Phone:401-944-7574
Practice Address - Fax:401-944-7602
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist