Healthcare Provider Details

I. General information

NPI: 1760144810
Provider Name (Legal Business Name): NATHAN DANIEL MCCORMACK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 E 1100 N
CHESTERTON IN
46304-9697
US

IV. Provider business mailing address

1460 STATE ST
HOBART IN
46342-6076
US

V. Phone/Fax

Practice location:
  • Phone: 219-926-5850
  • Fax:
Mailing address:
  • Phone: 765-810-6298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number05014345A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: