Healthcare Provider Details

I. General information

NPI: 1164488607
Provider Name (Legal Business Name): MELISSA MITCHELL MCCORMICK M.D., F.A.A.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD STE 7000
BATON ROUGE LA
70808-0307
US

IV. Provider business mailing address

781 COLONIAL DR
BATON ROUGE LA
70806-6537
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-8829
  • Fax: 225-765-8283
Mailing address:
  • Phone: 225-490-5440
  • Fax: 225-490-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number201439
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: