Healthcare Provider Details

I. General information

NPI: 1104998814
Provider Name (Legal Business Name): MICHAEL KEVIN MCCORMACK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 E LAUREL RD SUITE 3600
STRATFORD NJ
08084-1354
US

IV. Provider business mailing address

1030 BARNEGAT LN
MANTOLOKING NJ
08738-1620
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-6469
  • Fax:
Mailing address:
  • Phone: 732-899-1469
  • Fax: 732-899-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License Number25MS00001100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: