Basic Information
| Provider Information | |||||||||
| NPI: | 1215385927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | RALEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 MELROSE LN | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113631220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438305555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39 BROADWAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100063113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124401943 | ||||||||
| FaxNumber: | 7187652484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD298449 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD298449 | 01 | NY | STATE LICENSE NUMBER | OTHER |