Provider Demographics
NPI:1982677936
Name:MCCORMICK, MICHAEL H (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:H
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 STATE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-7601
Mailing Address - Country:US
Mailing Address - Phone:850-769-2417
Mailing Address - Fax:850-784-1144
Practice Address - Street 1:2202 STATE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-7601
Practice Address - Country:US
Practice Address - Phone:850-769-2417
Practice Address - Fax:850-784-1144
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2011-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051595174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1811917628OtherMEDICARE GRP NPI #
FL058854700Medicaid
FL14798OtherBLUE SHIELD
FL200012815OtherRAILROAD MEDICARE
FL593125723-A002OtherCHAMPUS/TRICARE
FL200012815OtherRAILROAD MEDICARE
FL058854700Medicaid
FLK4964Medicare PIN