Healthcare Provider Details

I. General information

NPI: 1760666267
Provider Name (Legal Business Name): ROBERT A MCCORMICK MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CALLE MEDICO SUITE 2
SANTA FE NM
87505-4705
US

IV. Provider business mailing address

11 CALLE MEDICO SUITE 2
SANTA FE NM
87505-4705
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-1003
  • Fax: 505-983-1008
Mailing address:
  • Phone: 505-983-1003
  • Fax: 505-983-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69164
License Number StateNM

VIII. Authorized Official

Name: DR. ROBERT A MCCORMICK
Title or Position: PRESIDENT
Credential: MD
Phone: 505-983-1003