Provider Demographics
NPI:1124037262
Name:MCDONOUGH, BRIAN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 824804
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-4804
Mailing Address - Country:US
Mailing Address - Phone:302-575-8040
Mailing Address - Fax:302-575-8005
Practice Address - Street 1:701 N CLAYTON ST
Practice Address - Street 2:MSB SUITE 200
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3165
Practice Address - Country:US
Practice Address - Phone:302-575-8040
Practice Address - Fax:302-575-8005
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002808207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE002973Medicare PIN
0000035301OtherDELAWARE PHYSICIANS
510064326OtherAETNA US HEALTHCARE
863638OtherALLIANCE
0696545000OtherAMER HEALTH
E12999Medicare UPIN
080167648OtherRR MEDICARE
002973F90Medicare ID - Type Unspecified
E12999OtherBCBS OF DE
54470OtherCOVENTRY
DE501490Medicare PIN