Provider Demographics
NPI:1831168608
Name:MCCORMACK, LAWRENCE R (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:R
Last Name:MCCORMACK
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 1:1031 PIERCE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4669
Mailing Address - Country:US
Mailing Address - Phone:419-557-5568
Mailing Address - Fax:419-557-5542
Practice Address - Street 1:703 TYLER ST
Practice Address - Street 2:STE 151
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-3392
Practice Address - Country:US
Practice Address - Phone:419-627-1056
Practice Address - Fax:419-627-6269
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034991207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0361791Medicaid
OH0445672Medicare PIN
OHH287150Medicare PIN
OH0361791Medicaid