Healthcare Provider Details

I. General information

NPI: 1306048160
Provider Name (Legal Business Name): JASON WAYNE MCCORMICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 SIERRA DR SUITE 400
GREENWOOD IN
46143-7240
US

IV. Provider business mailing address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-4800
  • Fax:
Mailing address:
  • Phone: 269-337-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301090001
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number01075850A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: