Basic Information
| Provider Information | |||||||||
| NPI: | 1588662464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCORMACK | ||||||||
| FirstName: | CAMPBELL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 BAINBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191471568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156293837 | ||||||||
| FaxNumber: | 2156295531 | ||||||||
| Practice Location | |||||||||
| Address1: | 331 WILMINGTON-WEST CHESTER PIKE | ||||||||
| Address2: | SUITE ONE | ||||||||
| City: | GLEN MILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193422277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105585866 | ||||||||
| FaxNumber: | 6105586103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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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 | 225100000X | PT016697 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.