Provider Demographics
NPI:1639197015
Name:MCCORMICK, ANGELA CHRISTINE (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:CHRISTINE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3376 66TH ST
Mailing Address - Street 2:
Mailing Address - City:PALO
Mailing Address - State:IA
Mailing Address - Zip Code:52324-9621
Mailing Address - Country:US
Mailing Address - Phone:319-436-4811
Mailing Address - Fax:319-363-2903
Practice Address - Street 1:625 32ND AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-3947
Practice Address - Country:US
Practice Address - Phone:319-363-2901
Practice Address - Fax:319-363-2903
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03655208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0434506Medicaid
IAF232553OtherMIDLANDS CHOICE
IAP00137447OtherRAILROAD MEDICARE
IA12250OtherWELLMARK BCBS
IA12250OtherWELLMARK BCBS