MEDICARE: KEITH MCCORMICK

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	172A00000X	Driver

General Provider Information

NPI Number	:	1255193959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH MCCORMICK

Provider Business Mailing Address
First Line	:	2480 OAKTREE PL
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2963
Country	:	US
Telephone Number	:	513-227-6830
Fax Number	:

Provider Business Practice Location Address
First Line	:	2480 OAKTREE PL
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2963
Country	:	US
Telephone Number	:	513-227-6830
Fax Number	:

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

Provider Enumeration Date	:	01/29/2024
Last Update Date	:	01/29/2024

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