Provider Demographics
NPI:1740298728
Name:MCCORMACK, THOMAS W JR (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:MCCORMACK
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1361 JENNINGS MILL ROAD
Mailing Address - Street 2:BUILDING 200 SUITE 201
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622
Mailing Address - Country:US
Mailing Address - Phone:706-316-1908
Mailing Address - Fax:706-316-2062
Practice Address - Street 1:1361 JENNINGS MILL ROAD
Practice Address - Street 2:BUILDING 200 SUITE 201
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622
Practice Address - Country:US
Practice Address - Phone:706-316-1908
Practice Address - Fax:706-316-2062
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
GAGA0512552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00958625AMedicaid
GA26BDJBNMedicare ID - Type Unspecified
GA00958625AMedicaid