Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 35058973 | OH |
Y | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | 35058973 | OH |
NPI | 1205922895 |
---|---|
Provider Name | Kenelm Mccormick |
First Address | Cleveland, OH 44110-2602 |
Second Address | Cleveland, OH 44110-2602 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2006 |
Last Update Date | 09/12/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000380130 | ANTHEM (01) | OH |
0824433 | (05) | OH |
E81744 | (02) | OH |