Provider Demographics
NPI:1972576213
Name:MCCORMICK, DOUGLAS P (FNP)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD
Practice Address - Street 2:SUITE 520
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4247
Practice Address - Country:US
Practice Address - Phone:864-455-9033
Practice Address - Fax:864-455-6559
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC84363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0409Medicaid
SCP01044300OtherRR MEDICARE
SCP109153640Medicare PIN
SCP109157951Medicare PIN
SCNP0409Medicaid