Basic Information
| Provider Information | |||||||||
| NPI: | 1003426149 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMACK | ||||||||
| FirstName: | JOSEPHINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FERREL | ||||||||
| OtherFirstName: | JOSEPHINE | ||||||||
| OtherMiddleName: | P. | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306556748 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Practice Location | |||||||||
| Address1: | 2923 N CALIFORNIA AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606187702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2020 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209020741 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.