Provider Demographics
NPI:1659578904
Name:MCCORMACK, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:934 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1913
Mailing Address - Country:US
Mailing Address - Phone:610-664-3400
Mailing Address - Fax:
Practice Address - Street 1:934 MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-1913
Practice Address - Country:US
Practice Address - Phone:610-664-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ79814Medicare UPIN
PA097118Medicare ID - Type Unspecified