Provider Demographics
NPI:1164412961
Name:MCDONNELL, MICHAEL S (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:MCDONNELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:306 W WASHINGTON AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2176
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:
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
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIMM012522207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114356430Medicaid
MI114356430Medicaid