Provider Demographics
NPI:1295098861
Name:MCCORMACK, ROSS BRIAN (PT DPT OCS)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:BRIAN
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:PT DPT OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:951-335-9825
Mailing Address - Fax:812-590-8333
Practice Address - Street 1:77622 COUNTRY CLUB DR STE G
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0447
Practice Address - Country:US
Practice Address - Phone:760-345-3087
Practice Address - Fax:760-345-6852
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist