Provider Demographics
NPI:1619261583
Name:CORMICAN, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:CORMICAN
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:770-219-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75043208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty