Healthcare Provider Details

I. General information

NPI: 1811962616
Provider Name (Legal Business Name): JERRY MICHAEL MCCORMICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: J MICHAEL MCCORMICK

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6845 LEE AVE N MAIL STOP 31400A
BROOKLYN CENTER MN
55429-1717
US

IV. Provider business mailing address

6845 LEE AVE N 31400A
BROOKLYN CENTER MN
55429-1717
US

V. Phone/Fax

Practice location:
  • Phone: 763-569-0300
  • Fax: 763-569-0311
Mailing address:
  • Phone: 763-503-4395
  • Fax: 763-503-4395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number29706
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number24722
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: