Provider Demographics
NPI:1053501320
Name:TERENCE J MCDONNELL MD PROFESSIONAL CORP
Entity Type:Organization
Organization Name:TERENCE J MCDONNELL MD PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-841-1266
Mailing Address - Street 1:2999 REGENT STREET
Mailing Address - Street 2:SUITE 710
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2117
Mailing Address - Country:US
Mailing Address - Phone:510-841-1266
Mailing Address - Fax:510-841-0423
Practice Address - Street 1:2999 REGENT STREET
Practice Address - Street 2:SUITE 710
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2117
Practice Address - Country:US
Practice Address - Phone:510-841-1266
Practice Address - Fax:510-841-0423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC326600207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35020Medicare UPIN
ZZZ07015ZMedicare PIN
CA00C326600Medicare Oscar/Certification