Healthcare Provider Details

I. General information

NPI: 1356831978
Provider Name (Legal Business Name): COLIN MCCORKLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 TREADWELL CT
LUTHERVILLE MD
21093-3764
US

IV. Provider business mailing address

20 TREADWELL CT
LUTHERVILLE MD
21093-3764
US

V. Phone/Fax

Practice location:
  • Phone: 443-608-9149
  • Fax:
Mailing address:
  • Phone: 443-608-9149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351051027
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number62090
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number9133
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: