MEDICARE: POLLY LOVE MCCORMACK MD

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	207W00000X	Ophthalmology Physician	28473	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	180009769	OTHER	MN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	54817MC	OTHER	MN	BCBS OF MN
2	0818315	OTHER	MN	MEDICA CHOICE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376549089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	POLLY LOVE MCCORMACK MD

Provider Business Mailing Address
First Line	:	5851 DULUTH ST
Second Line	:	STE 215
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-3956
Country	:	US
Telephone Number	:	763-546-8422
Fax Number	:	763-546-8114

Provider Business Practice Location Address
First Line	:	5851 DULUTH ST
Second Line	:	STE 215
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-3956
Country	:	US
Telephone Number	:	763-546-8422
Fax Number	:	763-546-8114

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	04/23/2013

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Directions to “ POLLY LOVE MCCORMACK MD” Practice Location

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