Healthcare Provider Details

I. General information

NPI: 1487764676
Provider Name (Legal Business Name): PATRICK J. MCNELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 NAPIER AVE
SAINT JOSEPH MI
49085-2112
US

IV. Provider business mailing address

6416 DEANS HILL RD
BERRIEN CENTER MI
49102-9750
US

V. Phone/Fax

Practice location:
  • Phone: 269-985-4632
  • Fax: 269-985-4623
Mailing address:
  • Phone: 269-985-4632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036-055852
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01059499A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301101997
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: