Provider Demographics
NPI:1922022599
Name:MCCORMICK, RICHARD (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:M
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:PO BOX 7337
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-7337
Mailing Address - Country:US
Mailing Address - Phone:706-543-3449
Mailing Address - Fax:
Practice Address - Street 1:1199 PRINCE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2797
Practice Address - Country:US
Practice Address - Phone:706-543-3449
Practice Address - Fax:706-543-5744
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041039207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE64255Medicare UPIN
GA05BDDQNMedicare PIN