Provider Demographics
NPI:1689658395
Name:MCCORMICK, ALICE G (DO)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:G
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5450 EAST DEER VALLEY DRIVE UNIT 3206
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054
Mailing Address - Country:US
Mailing Address - Phone:570-499-5144
Mailing Address - Fax:480-619-4098
Practice Address - Street 1:5450 EAST DEER VALLEY DRIVE UNIT 3206
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054
Practice Address - Country:US
Practice Address - Phone:570-499-5144
Practice Address - Fax:480-619-4098
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006893207R00000X
AZAZ006893207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001035898Medicaid
PAC33768Medicare UPIN
PA001035898Medicaid