Provider Demographics
NPI:1568858223
Name:MCCOY, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 SUPERIOR ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-4138
Mailing Address - Country:US
Mailing Address - Phone:708-406-3040
Mailing Address - Fax:708-406-3059
Practice Address - Street 1:1111 SUPERIOR ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4138
Practice Address - Country:US
Practice Address - Phone:708-406-3040
Practice Address - Fax:708-406-3059
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012750363L00000X
IL041321035163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse