Provider Demographics
NPI:1821018821
Name:MCCORMACK, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MCCORMACK
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 1:11110 MEDICAL CAMPUS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6700
Mailing Address - Country:US
Mailing Address - Phone:301-665-4731
Mailing Address - Fax:301-665-4711
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:STE 130
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-665-4731
Practice Address - Fax:301-665-4711
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0041667207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD152761400Medicaid
DC0005 F288OtherBS OF DC
MD523047-01OtherBS OF MD
MD900000660OtherRR MEDICARE
MD900000660OtherRR MEDICARE
MD152761400Medicaid