Provider Demographics
NPI:1225151558
Name:MCDONOUGH, PATRICK EARL (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:EARL
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 1:235 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:ST. CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024
Mailing Address - Country:US
Mailing Address - Phone:715-483-3221
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:235 STATE STREET
Practice Address - Street 2:
Practice Address - City:ST. CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024
Practice Address - Country:US
Practice Address - Phone:715-483-3221
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50910207QS0010X
WI54869207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1225151558Medicaid
MN1225151558Medicaid
WI004880186Medicare PIN