Provider Demographics
NPI:1588662464
Name:MCCORMACK, CAMPBELL IV (PT)
Entity Type:Individual
Prefix:MR
First Name:CAMPBELL
Middle Name:
Last Name:MCCORMACK
Suffix:IV
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:420 BAINBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-1568
Mailing Address - Country:US
Mailing Address - Phone:215-629-3837
Mailing Address - Fax:215-629-5531
Practice Address - Street 1:331 WILMINGTON-WEST CHESTER PIKE
Practice Address - Street 2:SUITE ONE
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-2277
Practice Address - Country:US
Practice Address - Phone:610-558-5866
Practice Address - Fax:610-558-6103
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016697225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA078573SAVMedicare PIN