1225080005 NPI number — THOMAS J. MCCORMACK DO

Table of content: THOMAS J. MCCORMACK DO (NPI 1225080005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225080005 NPI number — THOMAS J. MCCORMACK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCORMACK
Provider First Name:
THOMAS
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225080005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 MILL RD
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
FAIRHAVEN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02719-5252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-973-2000
Provider Business Mailing Address Fax Number:
508-973-2001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 ROSEBROOK WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAREHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02571-1138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-273-4950
Provider Business Practice Location Address Fax Number:
508-273-4951
Provider Enumeration Date:
05/17/2006

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: 207Q00000X , with the licence number:  79854 , 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: 110054517A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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