Provider Demographics
NPI:1093193419
Name:MCCORMICK, RON JR
Entity Type:Individual
Prefix:MR
First Name:RON
Middle Name:
Last Name:MCCORMICK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N MAIN ST # 122
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4211
Mailing Address - Country:US
Mailing Address - Phone:573-471-7074
Mailing Address - Fax:573-475-4109
Practice Address - Street 1:223 N MAIN ST # 122
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4211
Practice Address - Country:US
Practice Address - Phone:573-471-7074
Practice Address - Fax:573-475-4109
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO253Z00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator