Basic Information
| Provider Information | |||||||||
| NPI: | 1740362052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | CATHERINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FOREST ROAD 252 | ||||||||
| Address2: | |||||||||
| City: | TIJERAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870596308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032786680 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 CAMINO DE SALUD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871312934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059250460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | MD29172 | OR | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | MD2021-1008 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 500607350 | 05 | OR | MEDICAID | 2001733 | 05 | WA | MEDICAID |