Provider Demographics
NPI:1255193959
Name:MCCORMICK, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 OAKTREE PL
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2963
Mailing Address - Country:US
Mailing Address - Phone:513-227-6830
Mailing Address - Fax:
Practice Address - Street 1:2480 OAKTREE PL
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2963
Practice Address - Country:US
Practice Address - Phone:513-227-6830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver