Basic Information
| Provider Information | |||||||||
| NPI: | 1821075243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCORD | ||||||||
| FirstName: | MELIA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W PARK ST | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E ORANGE ST | ||||||||
| Address2: | HOOPESTON COMMUNITY MEMORIAL HOSPITAL DBA CHARLOTTE ANN | ||||||||
| City: | HOOPESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609421802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172835644 | ||||||||
| FaxNumber: | 2172837432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085-002550 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 085002550 | 01 | IL | STATE LICENSE NUMBER | OTHER | 108919 | 01 | IL | HEALTH ALLIANCE | OTHER |