Provider Demographics
NPI:1073809141
Name:MCCLINTOCK, AMY COLLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:COLLEEN
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 TROY RD STE 130
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2540
Mailing Address - Country:US
Mailing Address - Phone:618-463-7600
Mailing Address - Fax:
Practice Address - Street 1:2122 TROY RD STE 130
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-2540
Practice Address - Country:US
Practice Address - Phone:618-463-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036159591207QS0010X, 207Q00000X
OH123806207QS0010X
MO2015026147207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine