Provider Demographics
NPI:1790778496
Name:MCCORMICK, SHELLY C (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:C
Last Name:MCCORMICK
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 1:3811 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-398-7326
Mailing Address - Fax:
Practice Address - Street 1:503 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291
Practice Address - Country:US
Practice Address - Phone:318-329-8310
Practice Address - Fax:318-329-8313
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35C.000651208000000X, 208M00000X
MS305752080A0000X, 2080N0001X
LA0213542080N0001X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1551104Medicaid
OH0024372Medicaid