Provider Demographics
NPI:1750327763
Name:CORCORAN, MARY LOU (PT)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY LOU
Other - Middle Name:
Other - Last Name:BAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:510 TOWNE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1331
Mailing Address - Country:US
Mailing Address - Phone:315-637-4747
Mailing Address - Fax:315-637-6711
Practice Address - Street 1:510 TOWNE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1331
Practice Address - Country:US
Practice Address - Phone:315-637-4747
Practice Address - Fax:315-637-6711
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006344-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY955322OtherMVP
NY161303109OtherCIGNA
NY000151870OtherBSCNY
NY000921742001OtherHEALTHNOW NY
NY161303109OtherUNITED HEALTHCARE
NY5056028OtherAETNA
NYCC8703Medicare ID - Type UnspecifiedMEDICARE