1740210533 NPI number — DR. TIMOTHY J MCDONOUGH MD

Table of content: DR. TIMOTHY J MCDONOUGH MD (NPI 1740210533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740210533 NPI number — DR. TIMOTHY J MCDONOUGH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDONOUGH
Provider First Name:
TIMOTHY
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740210533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1713 CENTRAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201-1507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-869-1499
Provider Business Mailing Address Fax Number:
847-869-2932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3915 OGLESBY AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
GURNEE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60031-3358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-336-1600
Provider Business Practice Location Address Fax Number:
847-336-2380
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  036050102 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 036050102 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 036050102 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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