Provider Demographics
NPI:1114235413
Name:MCCORMICK, SCOTT B (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:B
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1167
Mailing Address - Country:US
Mailing Address - Phone:586-619-9986
Mailing Address - Fax:586-806-5085
Practice Address - Street 1:18 MARKET ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-7403
Practice Address - Country:US
Practice Address - Phone:586-783-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E012740OtherBCBS GROUP NUMBER
MI0N40170Medicare PIN