Provider Demographics
NPI:1083816565
Name:ODONOGHUE & ROSENOW, MDSC
Entity Type:Organization
Organization Name:ODONOGHUE & ROSENOW, MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ODONOGHUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-422-8500
Mailing Address - Street 1:2850 W 95TH ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2741
Mailing Address - Country:US
Mailing Address - Phone:708-422-8500
Mailing Address - Fax:708-499-7872
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:SUITE 306
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2741
Practice Address - Country:US
Practice Address - Phone:708-422-8500
Practice Address - Fax:708-499-7872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036054095208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036054095Medicaid
IL01616745OtherBLUE CROSS BLUE SHIELD
IL036054095Medicaid