Provider Demographics
NPI:1164482832
Name:MCCORMICK, CHARLES CALVIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CALVIN
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:1201 S MILLER ST
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801
Practice Address - Country:US
Practice Address - Phone:509-662-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60741962207Q00000X
WV14713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1164482832Medicaid
SC038894900Medicaid
WV0040807000Medicaid
SCSC74139167Medicare PIN