Basic Information
| Provider Information | |||||||||
| NPI: | 1376845370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAMMOND | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 COLUMBUS ST | ||||||||
| Address2: | |||||||||
| City: | HICKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435261250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195426692 | ||||||||
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| Practice Location | |||||||||
| Address1: | 208 COLUMBUS ST | ||||||||
| Address2: | |||||||||
| City: | HICKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195426692 | ||||||||
| FaxNumber: | 4195425667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2010 | ||||||||
| LastUpdateDate: | 08/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50.004015RX | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 10001240A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000000690186 | 01 | IN | ANTHEM | OTHER | 0203880 | 05 | OH | MEDICAID | 000000690186 | 01 | ANTHEM | OTHER | OPR | 05 | IN | MEDICAID |