Healthcare Provider Details

I. General information

NPI: 1164552998
Provider Name (Legal Business Name): KELLY MCCORMICK BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 E BURNSIDE ST
PORTLAND OR
97214-1535
US

IV. Provider business mailing address

1939 E BURNSIDE ST
PORTLAND OR
97214-1535
US

V. Phone/Fax

Practice location:
  • Phone: 503-233-6141
  • Fax: 503-233-2889
Mailing address:
  • Phone: 503-233-6141
  • Fax: 503-233-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-353618
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA00002483
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: