Basic Information
| Provider Information | |||||||||
| NPI: | 1700879830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | OWEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 N EMERSON AVE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461438895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178813937 | ||||||||
| FaxNumber: | 3178874008 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 N EMERSON AVE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461438895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178813937 | ||||||||
| FaxNumber: | 3178874008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 02/01/2010 | ||||||||
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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 | 207W00000X | 01026314A | IN | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 000000011606 | 01 | IN | MPLAN | OTHER | 352129520 | 01 | IN | UNITED MINE WORKERS | OTHER | 000000214798 | 01 | IN | BCBS | OTHER | 180044022 | 01 | IN | RAILROAD MEDICARE | OTHER | 100154690 | 05 | IN | MEDICAID | 000000011606 | 01 | IN | SENIOR SMART CHOICE | OTHER | 154727 | 01 | IN | COLE VISION | OTHER | AETNA | 01 | IN | AETNA | OTHER |