Provider Demographics
NPI:1124302633
Name:MCCORD, GEOFFREY A (NP)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:A
Last Name:MCCORD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 W. MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302
Mailing Address - Country:US
Mailing Address - Phone:708-386-1000
Mailing Address - Fax:
Practice Address - Street 1:7900 W JEFFERSON BLVD STE 306
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-458-3610
Practice Address - Fax:260-458-3611
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003735A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily