MEDICARE: VAN SCOTT MCCORKLE 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	2080A0000X	Pediatric Adolescent Medicine Physician	40734	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538157839
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VAN SCOTT MCCORKLE MD

Provider Business Mailing Address
First Line	:	1520B JENNINGS MILL RD
Second Line	:
City	:	BOGART
State	:	GA
Zip	:	30622-2543
Country	:	US
Telephone Number	:	706-548-1216
Fax Number	:	706-548-1772

Provider Business Practice Location Address
First Line	:	1520B JENNINGS MILL RD
Second Line	:
City	:	BOGART
State	:	GA
Zip	:	30622-2543
Country	:	US
Telephone Number	:	706-548-1216
Fax Number	:	706-548-1772

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

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	07/09/2007

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