Provider Demographics
NPI:1083679971
Name:JACKSON OB/GYN
Entity Type:Organization
Organization Name:JACKSON OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-787-0334
Mailing Address - Street 1:300 W WASHINGTON AVE
Mailing Address - Street 2:STE 60
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2180
Mailing Address - Country:US
Mailing Address - Phone:517-787-0334
Mailing Address - Fax:517-787-2114
Practice Address - Street 1:300 W WASHINGTON AVE
Practice Address - Street 2:STE 60
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2180
Practice Address - Country:US
Practice Address - Phone:517-787-0334
Practice Address - Fax:517-787-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMM012522174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG73596Medicare UPIN