Provider Demographics
NPI:1922100700
Name:MCCORMACK, EDWARD JOHN JR (PT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHN
Last Name:MCCORMACK
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 SW 7TH CT
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-6951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7200 W CAMINO REAL
Practice Address - Street 2:SUITE 101
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5511
Practice Address - Country:US
Practice Address - Phone:561-789-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 4994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT04994OtherPHYSICAL THERAPY LICENSE
FLPT04994OtherPHYSICAL THERAPY LICENSE
IN232280Medicare PIN