Healthcare Provider Details

I. General information

NPI: 1124284047
Provider Name (Legal Business Name): SHELLY C. MCCORMICK MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 WOODSIDE DR
MONROE LA
71201-2140
US

IV. Provider business mailing address

3811 WOODSIDE DR
MONROE LA
71201-2140
US

V. Phone/Fax

Practice location:
  • Phone: 318-376-3379
  • Fax:
Mailing address:
  • Phone: 318-376-3379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: SHELLY C MCCORMICK
Title or Position: OWNER
Credential: MD
Phone: 318-398-7326