Provider Demographics
NPI:1891887543
Name:MCCORMACK, PATRICIA C (MD)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:C
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-1578
Mailing Address - Country:US
Mailing Address - Phone:718-698-9572
Mailing Address - Fax:718-698-9573
Practice Address - Street 1:1550 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1578
Practice Address - Country:US
Practice Address - Phone:718-698-9572
Practice Address - Fax:718-698-9573
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161216207N00000X
NJ25MA04075800207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400068335Medicare PIN
NJ500045Medicare PIN