Provider Demographics
NPI:1851666226
Name:MCGRORY, MIKAELA LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:LYNNE
Last Name:MCGRORY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4264
Mailing Address - Country:US
Mailing Address - Phone:312-635-0973
Mailing Address - Fax:813-290-9691
Practice Address - Street 1:8200 W. ROOSEVELT ROAD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2528
Practice Address - Country:US
Practice Address - Phone:708-488-9850
Practice Address - Fax:708-488-9870
Is Sole Proprietor?:No
Enumeration Date:2012-03-18
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004288363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004288OtherLICENSE NO
ILF400227826,7829,7831Medicare PIN