Provider Demographics
NPI:1023214962
Name:MCDONOUGH, TROY MICHAEL (MSPT)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:MICHAEL
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1215 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5400
Practice Address - Country:US
Practice Address - Phone:515-956-4095
Practice Address - Fax:515-956-4093
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1768PT2251X0800X
IA005262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT00006175OtherBLUE CROSS
MT0000344097Medicaid
MT000060776OtherBLUE CROSS FOR SEELY LAKE
MT000060776OtherBLUE CROSS FOR SEELY LAKE