Basic Information
| Provider Information | |||||||||
| NPI: | 1386686368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STATEN-MCCORMICK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 S KALAMAZOO MALL | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490074832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693433900 | ||||||||
| FaxNumber: | 2693435640 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 S KALAMAZOO MALL | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490074832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693433900 | ||||||||
| FaxNumber: | 2693435640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 03/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 4301046064 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 10/2698723 | 05 | MI | MEDICAID | 104686810 | 05 | MI | MEDICAID |