Healthcare Provider Details

I. General information

NPI: 1922135136
Provider Name (Legal Business Name): MICHAEL PATRICK MCCORMACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 MERCY DR NW SUITE 522
CANTON OH
44708-2626
US

IV. Provider business mailing address

1330 MERCY DR NW SUITE 522
CANTON OH
44708-2626
US

V. Phone/Fax

Practice location:
  • Phone: 330-588-4856
  • Fax: 330-588-4857
Mailing address:
  • Phone: 330-588-4856
  • Fax: 330-588-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number34.009124
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: