Provider Demographics
NPI:1790792562
Name:MCCAMMACK, EDWIN W (PA)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:W
Last Name:MCCAMMACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3909
Mailing Address - Country:US
Mailing Address - Phone:217-366-8107
Mailing Address - Fax:217-366-6106
Practice Address - Street 1:101 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3909
Practice Address - Country:US
Practice Address - Phone:217-366-1243
Practice Address - Fax:217-366-6106
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000055363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00328875OtherRAILROAD MEDICARE
434110OtherMEDICARE GROUP
L72226Medicare PIN
P00328875OtherRAILROAD MEDICARE
S86214Medicare UPIN