1215001680 NPI number — DR. PAUL GLEN MCCORMICK PH.D.

Table of content: DR. PAUL GLEN MCCORMICK PH.D. (NPI 1215001680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215001680 NPI number — DR. PAUL GLEN MCCORMICK PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCORMICK
Provider First Name:
PAUL
Provider Middle Name:
GLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCORMICK
Provider Other First Name:
PAUL
Provider Other Middle Name:
GLEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1215001680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
271 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
STONEHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02180-3591
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-438-5550
Provider Business Mailing Address Fax Number:
781-438-5553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
271 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
STONEHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02180-3591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-438-5550
Provider Business Practice Location Address Fax Number:
781-438-5553
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  4192 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1899236 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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