Provider Demographics
NPI:1962480335
Name:MCCORMACK, JANICE (MD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
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 1:540 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-3105
Mailing Address - Country:US
Mailing Address - Phone:631-669-2555
Mailing Address - Fax:631-669-3051
Practice Address - Street 1:540 UNION BLVD
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-3105
Practice Address - Country:US
Practice Address - Phone:631-669-2555
Practice Address - Fax:631-669-3051
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170843207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01407634Medicaid
NYA400029341Medicare PIN
NY01407634Medicaid