Provider Demographics
NPI:1043488166
Name:MIRANDA MCCORMACK, M.D., LLC
Entity type:Organization
Organization Name:MIRANDA MCCORMACK, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:CHRISTIE
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-616-2224
Mailing Address - Street 1:5040 SW GRIFFITH DR
Mailing Address - Street 2:#201
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2985
Mailing Address - Country:US
Mailing Address - Phone:503-616-2224
Mailing Address - Fax:
Practice Address - Street 1:5040 SW GRIFFITH DR
Practice Address - Street 2:#201
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2985
Practice Address - Country:US
Practice Address - Phone:503-616-2224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR465592-90261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH73664Medicare UPIN