Provider Demographics
NPI:1588924054
Name:MCCORMACK, SHANNON E (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E HUEBBE PKWY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:BELOIT MEMORIAL HOSPITAL
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-363-5971
Practice Address - Fax:608-363-5737
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019893207R00000X, 390200000X
WI64097-21207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100045471Medicaid