Healthcare Provider Details

I. General information

NPI: 1588669394
Provider Name (Legal Business Name): MICHAEL A MCCORMACK MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7423 S MASON MONTGOMERY RD
MASON OH
45040-7828
US

IV. Provider business mailing address

7423 S MASON MONTGOMERY RD
MASON OH
45040-7828
US

V. Phone/Fax

Practice location:
  • Phone: 513-347-9999
  • Fax: 513-573-9178
Mailing address:
  • Phone: 513-347-9999
  • Fax: 513-573-9178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT06009
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT002212
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: