Healthcare Provider Details

I. General information

NPI: 1952492076
Provider Name (Legal Business Name): BARRY DODD MCCORMICK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 WILBORN AVE
SOUTH BOSTON VA
24592-1645
US

IV. Provider business mailing address

422 HAMILTON BLVD
SOUTH BOSTON VA
24592-5200
US

V. Phone/Fax

Practice location:
  • Phone: 434-517-3123
  • Fax:
Mailing address:
  • Phone: 434-572-4074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110002391
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002391
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: