MEDICARE: MR. MICHAEL JOHN MCCORMICK 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		IL

General Provider Information

NPI Number	:	1477540854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL JOHN MCCORMICK ATC

Provider Business Mailing Address
First Line	:	460 BRADFORD CIR
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3312
Country	:	US
Telephone Number	:	630-928-3400
Fax Number	:	773-549-2743

Provider Business Practice Location Address
First Line	:	1323 W DIVERSEY PKWY
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1207
Country	:	US
Telephone Number	:	773-549-2520
Fax Number	:	773-549-2743

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/08/2007

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