Provider Demographics
NPI:1558727990
Name:MCCORMICK PHYSICAL THERAPY & ATHLETIC REHAB
Entity Type:Organization
Organization Name:MCCORMICK PHYSICAL THERAPY & ATHLETIC REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:618-660-8097
Mailing Address - Street 1:131 GREENBRIER LN
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010
Mailing Address - Country:US
Mailing Address - Phone:618-660-8097
Mailing Address - Fax:
Practice Address - Street 1:131 GREENBRIER LN
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010
Practice Address - Country:US
Practice Address - Phone:618-660-8097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty