Healthcare Provider Details

I. General information

NPI: 1952693707
Provider Name (Legal Business Name): ISHA L MCCONKEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY STE 205
ALTON IL
62002-4569
US

IV. Provider business mailing address

2 SAINT ANTHONYS WAY STE 205
ALTON IL
62002-4569
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-2222
  • Fax: 618-463-5004
Mailing address:
  • Phone: 618-463-2222
  • Fax: 618-463-5004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.011181
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036158038
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: