Basic Information
| Provider Information | |||||||||
| NPI: | 1831242841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 468 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049760468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078588353 | ||||||||
| FaxNumber: | 2074749261 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 FAIRVIEW AVE STE 225 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049761481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074746265 | ||||||||
| FaxNumber: | 2074748365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2007 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD17639 | ME | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD 2007-0002 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD-061821-L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 9600207 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1831242841 | 05 | ME | MEDICAID |