Provider Demographics
NPI:1386686368
Name:STATEN-MCCORMICK, MARY B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:B
Last Name:STATEN-MCCORMICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:125 S KALAMAZOO MALL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-4832
Mailing Address - Country:US
Mailing Address - Phone:269-343-3900
Mailing Address - Fax:269-343-5640
Practice Address - Street 1:125 S KALAMAZOO MALL
Practice Address - Street 2:SUITE 204
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4832
Practice Address - Country:US
Practice Address - Phone:269-343-3900
Practice Address - Fax:269-343-5640
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301046064207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10/2698723Medicaid
MI104686810Medicaid
MIP08090006Medicare ID - Type UnspecifiedALLEGAN
MI104686810Medicaid
MI0C96159005Medicare ID - Type UnspecifiedBRONSON