Healthcare Provider Details

I. General information

NPI: 1104168442
Provider Name (Legal Business Name): KATHLEEN MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 708-327-3041
  • Fax: 708-327-3489
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number018.001867
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: