Healthcare Provider Details

I. General information

NPI: 1023000908
Provider Name (Legal Business Name): BOYD A. MCCRACKEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HEALTH CARE DR
GREENVILLE IL
62246-1155
US

IV. Provider business mailing address

201 HEALTH CARE DR
GREENVILLE IL
62246-1155
US

V. Phone/Fax

Practice location:
  • Phone: 618-664-1380
  • Fax: 618-664-4239
Mailing address:
  • Phone: 618-664-1380
  • Fax: 618-664-4239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036052523
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: