Provider Demographics
NPI:1215385927
Name:MCCORMICK, STEPHEN RALEY (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RALEY
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 1:9 MELROSE LN
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11363-1220
Mailing Address - Country:US
Mailing Address - Phone:843-830-5555
Mailing Address - Fax:
Practice Address - Street 1:39 BROADWAY FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-3113
Practice Address - Country:US
Practice Address - Phone:212-440-1943
Practice Address - Fax:718-765-2484
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD298449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMD298449OtherSTATE LICENSE NUMBER