Provider Demographics
NPI:1114917234
Name:MCCORMICK, KEVIN (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-9702
Mailing Address - Country:US
Mailing Address - Phone:315-624-8300
Mailing Address - Fax:315-624-8328
Practice Address - Street 1:3946 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-9702
Practice Address - Country:US
Practice Address - Phone:315-624-8300
Practice Address - Fax:315-624-8328
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178068-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01150774Medicaid
NY110186365OtherRRMCR
NYE15700Medicare UPIN
NYBB3744Medicare ID - Type UnspecifiedMEDICARE