MEDICARE: COLLEEN A. MCCORMICK CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	101-0017589	VT
2	367500000X	Certified Registered Nurse Anesthetist	5039101	NY

General Provider Information

NPI Number	:	1407831944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN A. MCCORMICK CRNA

Provider Business Mailing Address
First Line	:	21 WILDWOOD EST
Second Line	:
City	:	PLATTSBURGH
State	:	NY
Zip	:	12901-5002
Country	:	US
Telephone Number	:	518-561-2214
Fax Number	:

Provider Business Practice Location Address
First Line	:	216 LOGAN LN
Second Line	:	CRNA - MEDICAL DOCTOR ASSOCIATES
City	:	MAHOPAC
State	:	NY
Zip	:	10541-3650
Country	:	US
Telephone Number	:	888-400-8878
Fax Number	:	845-621-1911

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	07/08/2007

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