1538359690 NPI number — JENNY KRISTIN MCCORMICK MD

Table of content: JENNY KRISTIN MCCORMICK MD (NPI 1538359690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538359690 NPI number — JENNY KRISTIN MCCORMICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCORMICK
Provider First Name:
JENNY
Provider Middle Name:
KRISTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOTTOMLY
Provider Other First Name:
JENNY
Provider Other Middle Name:
KRISTIN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538359690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PSSB BUILDING, 4150 V STREET, #2100
Provider Second Line Business Mailing Address:
DEPARTMENT OF EMERGENCY MEDICINE UC DAVIS SOM
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-852-3761
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PSSB BUILDING, 4150 V STREET, #2100
Provider Second Line Business Practice Location Address:
DEPARTMENT OF EMERGENCY MEDICINE UC DAVIS SOM
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-734-8568
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2007

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: 207P00000X , with the licence number:  218597 , 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)