Basic Information
| Provider Information | |||||||||
| NPI: | 1952693707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONKEY | ||||||||
| FirstName: | ISHA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 MAPLE SUMMIT RD | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184982101 | ||||||||
| FaxNumber: | 6184988153 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 MAPLE SUMMIT RD | ||||||||
| Address2: | ILLINI BLDG | ||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184982101 | ||||||||
| FaxNumber: | 6184988153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 036158038 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34.011181 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 376013958 | 01 | IL | IRS | OTHER | 0115016 | 05 | OH | MEDICAID |