Provider Demographics
NPI:1871020644
Name:MACCORMICK, SAMUEL JOHN (MBBCH, BAO)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JOHN
Last Name:MACCORMICK
Suffix:
Gender:M
Credentials:MBBCH, BAO
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 800136
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908
Mailing Address - Country:US
Mailing Address - Phone:434-924-8145
Mailing Address - Fax:434-244-9438
Practice Address - Street 1:1215 LEE STREET
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908
Practice Address - Country:US
Practice Address - Phone:434-924-9508
Practice Address - Fax:434-982-0019
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program