Provider Demographics
NPI:1942362702
Name:MCCORMICK, GERALD LANE (DO)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LANE
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 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:255 W 5TH ST SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2819
Practice Address - Country:US
Practice Address - Phone:706-295-3855
Practice Address - Fax:706-235-5875
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025219207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000268177HMedicaid
D40593Medicare UPIN
GA83BBBLPMedicare ID - Type Unspecified