Basic Information
| Provider Information | |||||||||
| NPI: | 1679528616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCORKINDALE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | O. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 328 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511020328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122795830 | ||||||||
| FaxNumber: | 7122795883 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 E 14TH ST | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687871152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023752500 | ||||||||
| FaxNumber: | 4023752463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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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 | 207Q00000X | 19231 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 29362 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 17827 | 01 | IA | WELLMARK BCBS - MAPLE VAL | OTHER | 7085498 | 05 | NE | MEDICAID | 8085498 | 05 | IA | MEDICAID |