MEDICARE: MR. COREY MCDEVITT ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2601001377	MI
2	2255A2300X	Athletic Trainer	003023-1	NY

General Provider Information

NPI Number	:	1184029837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COREY MCDEVITT ATC

Provider Business Mailing Address
First Line	:	6795 RAVENWOOD AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-6634
Country	:	US
Telephone Number	:	330-265-1475
Fax Number	:

Provider Business Practice Location Address
First Line	:	6795 RAVENWOOD AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-6634
Country	:	US
Telephone Number	:	330-265-1475
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2014
Last Update Date	:	11/11/2015

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