Healthcare Provider Details

I. General information

NPI: 1265342299
Provider Name (Legal Business Name): KIERAN MICHAEL MCCORMACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 S TERRY AVE
ORLANDO FL
32805-1843
US

IV. Provider business mailing address

25 S TERRY AVE
ORLANDO FL
32805-1843
US

V. Phone/Fax

Practice location:
  • Phone: 800-974-0554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT45033
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: