Provider Demographics
NPI:1235103938
Name:MCCORMICK, MICHAEL A (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
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 1:322 EDGEHILL RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-4716
Mailing Address - Country:US
Mailing Address - Phone:256-483-8447
Mailing Address - Fax:610-688-8643
Practice Address - Street 1:107 TOWN CENTER RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2330
Practice Address - Country:US
Practice Address - Phone:610-401-8368
Practice Address - Fax:610-688-8643
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS011923208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529926920Medicaid
AL51004012OtherBC BS ALABAMA #
AL51004012OtherBC BS ALABAMA #