MEDICARE: CEDRIC JUAN MCKOY APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	209005033	IL

General Provider Information

NPI Number	:	1952529372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CEDRIC JUAN MCKOY APN

Provider Business Mailing Address
First Line	:	9525 S SPAULDING AVE
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2200
Country	:	US
Telephone Number	:	773-372-5113
Fax Number	:

Provider Business Practice Location Address
First Line	:	5841 S MARYLAND AVE # 2030
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1447
Country	:	US
Telephone Number	:	773-834-7854
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	08/18/2015

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