Healthcare Provider Details

I. General information

NPI: 1306993795
Provider Name (Legal Business Name): JOHN C MCCORMACK PHD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 WRIGHTSBORO RD
AUGUSTA GA
30904-6219
US

IV. Provider business mailing address

2301 WRIGHTSBORO RD
AUGUSTA GA
30904-6219
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-7029
  • Fax: 706-733-1376
Mailing address:
  • Phone: 706-733-7029
  • Fax: 706-733-1376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY000601
License Number StateGA

VIII. Authorized Official

Name: DR. JOHN COLLINS MCCORMACK
Title or Position: PRESIDENT
Credential: PHD
Phone: 706-733-7029