MEDICARE: MRS. PATRICIA C MCCORMACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	161216	NY
2	207N00000X	Dermatology Physician	25MA04075800	NJ

General Provider Information

NPI Number	:	1891887543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PATRICIA C MCCORMACK M.D.

Provider Business Mailing Address
First Line	:	1550 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1578
Country	:	US
Telephone Number	:	718-698-9572
Fax Number	:	718-698-9573

Provider Business Practice Location Address
First Line	:	1550 RICHMOND AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1578
Country	:	US
Telephone Number	:	718-698-9572
Fax Number	:	718-698-9573

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	05/28/2013

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