Provider Demographics
NPI:1275537532
Name:MCCORMICK, THOMAS R (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
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 1:24001 GREATER MACK AVE
Mailing Address - Street 2:STE B
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1407
Mailing Address - Country:US
Mailing Address - Phone:586-774-5050
Mailing Address - Fax:586-774-1808
Practice Address - Street 1:24001 GREATER MACK AVE
Practice Address - Street 2:STE B
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1407
Practice Address - Country:US
Practice Address - Phone:586-774-5050
Practice Address - Fax:586-774-1808
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0411432084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3021701 TYPE 10Medicaid
0E04717-0261-002Medicare ID - Type Unspecified
MI3021701 TYPE 10Medicaid