Basic Information
Provider Information | |||||||||
NPI: | 1619137577 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCORMICK | ||||||||
FirstName: | JACOB | ||||||||
MiddleName: | CATTELL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCCORMICK | ||||||||
OtherFirstName: | JACOB | ||||||||
OtherMiddleName: | CATTELL | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 13579 | ||||||||
Address2: |   | ||||||||
City: | READING | ||||||||
State: | PA | ||||||||
PostalCode: | 196123579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4846280799 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 420 S 5TH AVE | ||||||||
Address2: |   | ||||||||
City: | WEST READING | ||||||||
State: | PA | ||||||||
PostalCode: | 196112143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4846283637 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2008 | ||||||||
LastUpdateDate: | 04/11/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MT188224 | PA | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD436665 | PA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | MT188224 | 01 | PA | MEDICAL TRAINING LICENSE NUMBER | OTHER |