Healthcare Provider Details

I. General information

NPI: 1548204597
Provider Name (Legal Business Name): MICHAEL E MCCORMICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 PALMETTO RD
RAYVILLE LA
71269-6415
US

IV. Provider business mailing address

86 PALMETTO RD
RAYVILLE LA
71269-6415
US

V. Phone/Fax

Practice location:
  • Phone: 318-728-2970
  • Fax: 318-728-7111
Mailing address:
  • Phone: 318-728-2970
  • Fax: 318-729-7111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12771R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number12771R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: