Healthcare Provider Details

I. General information

NPI: 1275973844
Provider Name (Legal Business Name): TARA M MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

IV. Provider business mailing address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-2000
  • Fax:
Mailing address:
  • Phone: 605-995-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1146
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: