Healthcare Provider Details

I. General information

NPI: 1790778496
Provider Name (Legal Business Name): SHELLY CAROL MCCORMICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 11/02/2026
Certification Date: 11/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201-7407
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4541
  • Fax: 318-966-4543
Mailing address:
  • Phone: 318-966-4541
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.63225
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number30575
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number021354
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35C.000651
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number021354
License Number StateLA
# 6
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number30575
License Number StateMS
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0063225
License Number StateCO
# 8
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35C.000651
License Number StateOH
# 9
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number021354
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: