MEDICARE: KATHLEEN ANN MCCORMICK MD

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	207Q00000X	Family Medicine Physician	15379	AZ
2	207Q00000X	Family Medicine Physician	MD60125725	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P01039121	OTHER	WA	RR MEDICARE - PH&S

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427013275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN ANN MCCORMICK MD

Provider Business Mailing Address
First Line	:	PO BOX 3158
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3158
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 NW 12TH AVE
Second Line	:	SUITE 107
City	:	BATTLE GROUND
State	:	WA
Zip	:	98604-9141
Country	:	US
Telephone Number	:	360-687-6650
Fax Number	:

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

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	02/08/2013

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