Provider Demographics
NPI:1487764676
Name:MCNELLIS, PATRICK J (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:MCNELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 DEANS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49102-9750
Mailing Address - Country:US
Mailing Address - Phone:269-985-4632
Mailing Address - Fax:
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2112
Practice Address - Country:US
Practice Address - Phone:269-985-4632
Practice Address - Fax:269-985-4623
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-055852208M00000X
IN01059499A207R00000X
MI4301101997208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000743297OtherBCBS
IL036055852Medicaid
IN200989440Medicaid
IN200989440Medicaid
ILK08976Medicare PIN
INM400060323Medicare PIN