Provider Demographics
NPI:1811962616
Name:MCCORMICK, JERRY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:MICHAEL
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:MICHAEL
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6845 LEE AVE N
Mailing Address - Street 2:31400A
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1717
Mailing Address - Country:US
Mailing Address - Phone:763-503-4395
Mailing Address - Fax:763-503-4395
Practice Address - Street 1:6845 LEE AVE N
Practice Address - Street 2:MAIL STOP 31400A
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1717
Practice Address - Country:US
Practice Address - Phone:763-569-0300
Practice Address - Fax:763-569-0311
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29706207N00000X
WI24722207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN158380800Medicaid
MN070000616Medicare ID - Type Unspecified
MN158380800Medicaid