Provider Demographics
NPI:1952693707
Name:MCCONKEY, ISHA L (DO)
Entity type:Individual
Prefix:
First Name:ISHA
Middle Name:L
Last Name:MCCONKEY
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SAINT ANTHONYS WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-463-2222
Mailing Address - Fax:618-463-5004
Practice Address - Street 1:2 SAINT ANTHONYS WAY STE 205
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-463-2222
Practice Address - Fax:618-463-5004
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.011181207Q00000X
390200000X
IL036158038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0115016Medicaid
IL376013958OtherIRS
OHH429791Medicare PIN