MEDICARE: MATTHEW 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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1568040632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW MCCORMICK

Provider Business Mailing Address
First Line	:	RT 2 BOX 94C
Second Line	:
City	:	LEON
State	:	WV
Zip	:	25123
Country	:	US
Telephone Number	:	304-593-5913
Fax Number	:

Provider Business Practice Location Address
First Line	:	198 WOODRUM LN
Second Line	:
City	:	WEST COLUMBIA
State	:	WV
Zip	:	25287-9723
Country	:	US
Telephone Number	:	304-593-5913
Fax Number	:

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

Provider Enumeration Date	:	03/31/2021
Last Update Date	:	03/31/2021

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