Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 MCMILLAN RD
WEST MONROE LA
71291
US

IV. Provider business mailing address

3811 WOODSIDE DR
MONROE LA
71201
US

V. Phone/Fax

Practice location:
  • Phone: 318-329-8310
  • Fax: 318-329-8313
Mailing address:
  • Phone: 318-398-7326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: