MEDICARE: MRS. SHELLY C MCCORMICK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	021354	LA
2	208000000X	Pediatrics Physician	DR.63225	CO
3	2080N0001X	Neonatal-Perinatal Medicine Physician	30575	MS
4	2080N0001X	Neonatal-Perinatal Medicine Physician	021354	LA
5	208M00000X	Hospitalist Physician	35C.000651	OH
6	2080A0000X	Pediatric Adolescent Medicine Physician	30575	MS
7	208000000X	Pediatrics Physician	DR.0063225	CO
8	208000000X	Pediatrics Physician	35C.000651	OH
9	208000000X	Pediatrics Physician	021354	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790778496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHELLY C MCCORMICK M.D.

Provider Business Mailing Address
First Line	:	1541 KINGS HWY
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-4228
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	503 MCMILLAN RD
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291
Country	:	US
Telephone Number	:	318-329-8310
Fax Number	:	318-329-8313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	06/03/2026

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