1598996399 NPI number — DR. SHAELAN MCCORMICK OD

Table of content: DR. SHAELAN MCCORMICK OD (NPI 1598996399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598996399 NPI number — DR. SHAELAN MCCORMICK OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCORMICK
Provider First Name:
SHAELAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1598996399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 PLAZA CT
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
EAST STROUDSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18301-8260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-421-8842
Provider Business Mailing Address Fax Number:
570-476-5842

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 COMMUNITY DR
Provider Second Line Business Practice Location Address:
SUITE 204A
Provider Business Practice Location Address City Name:
TOBYHANNA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18466-8985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-895-4550
Provider Business Practice Location Address Fax Number:
570-895-4461
Provider Enumeration Date:
07/29/2009

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: 152W00000X , with the licence number:  OEG002244 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1023389000001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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