Provider Demographics
NPI:1043224041
Name:MARY MCDONALD MD SC
Entity Type:Organization
Organization Name:MARY MCDONALD MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LENZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-426-2211
Mailing Address - Street 1:3420 JACKSON ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-8144
Mailing Address - Country:US
Mailing Address - Phone:920-426-2211
Mailing Address - Fax:920-426-2231
Practice Address - Street 1:2700 W 9TH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7247
Practice Address - Country:US
Practice Address - Phone:920-223-0490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28027020207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21299800Medicaid
WI=========012OtherBLUE CROSS BLUE SHIELD
WI=========012OtherBLUE CROSS BLUE SHIELD
WIDE5687Medicare ID - Type UnspecifiedTRAVELERS MC
WIB54939Medicare UPIN
WI21299800Medicaid