Healthcare Provider Details

I. General information

NPI: 1891887543
Provider Name (Legal Business Name): PATRICIA C MCCORMACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 RICHMOND AVE
STATEN ISLAND NY
10314-1578
US

IV. Provider business mailing address

1550 RICHMOND AVE
STATEN ISLAND NY
10314-1578
US

V. Phone/Fax

Practice location:
  • Phone: 718-698-9572
  • Fax: 718-698-9573
Mailing address:
  • Phone: 718-698-9572
  • Fax: 718-698-9573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number161216
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA04075800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: