Provider Demographics
NPI:1801948740
Name:MCCORMICK, JAYNE MARIE (MD)
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:MARIE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:8300 CONSTITUTION AVE NE
Practice Address - Street 2:KASEMAN HOSPICE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7613
Practice Address - Country:US
Practice Address - Phone:505-559-1000
Practice Address - Fax:505-559-7015
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-06922086H0002X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086H0002XAllopathic & Osteopathic PhysiciansSurgeryHospice and Palliative Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1699730663OtherGROUP NPI
NE47084573713Medicaid
NE1699730663OtherGROUP NPI
NEF86216Medicare UPIN