Provider Demographics
NPI:1588660708
Name:MCCORMICK, RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
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 1:2409 CHERRY ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-2625
Mailing Address - Country:US
Mailing Address - Phone:419-251-4316
Mailing Address - Fax:419-251-3572
Practice Address - Street 1:2409 CHERRY ST
Practice Address - Street 2:SUITE 207
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2625
Practice Address - Country:US
Practice Address - Phone:419-251-4316
Practice Address - Fax:419-251-3572
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35044594207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35044594OtherOHIO LICENSE #
OH0426024Medicaid
OH207R00000XOtherTAXONOMY CODE
OH0426024Medicaid
OH35044594OtherOHIO LICENSE #