Provider Demographics
NPI:1851397327
Name:MCCORMACK, THOMAS P (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
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 1:60 BRIGHAM ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-2208
Mailing Address - Country:US
Mailing Address - Phone:508-999-6245
Mailing Address - Fax:
Practice Address - Street 1:60 BRIGHAM ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2208
Practice Address - Country:US
Practice Address - Phone:508-999-6245
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39439174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2042169Medicaid
MAK11252Medicare ID - Type Unspecified
MA2042169Medicaid