Healthcare Provider Details

I. General information

NPI: 1740298728
Provider Name (Legal Business Name): THOMAS W MCCORMACK JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 JENNINGS MILL ROAD BUILDING 200 SUITE 201
BOGART GA
30622
US

IV. Provider business mailing address

1361 JENNINGS MILL ROAD BUILDING 200 SUITE 201
BOGART GA
30622
US

V. Phone/Fax

Practice location:
  • Phone: 706-316-1908
  • Fax: 706-316-2062
Mailing address:
  • Phone: 706-316-1908
  • Fax: 706-316-2062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberGA051255
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: