Healthcare Provider Details

I. General information

NPI: 1134209943
Provider Name (Legal Business Name): KATHLEEN MARIE MCCOY RDMS, BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 CAREW ST
FORT WAYNE IN
46805-4705
US

IV. Provider business mailing address

309 GROVE ST
ALBION IN
46701-1089
US

V. Phone/Fax

Practice location:
  • Phone: 260-481-4785
  • Fax:
Mailing address:
  • Phone: 260-636-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number12343
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: