Provider Demographics
NPI:1235195587
Name:MACDONALD, MARY CAROL (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAROL
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CAROL
Other - Last Name:UDELHOFEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1060 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3434
Mailing Address - Country:US
Mailing Address - Phone:630-208-7867
Mailing Address - Fax:
Practice Address - Street 1:77 N AIRLITE ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4912
Practice Address - Country:US
Practice Address - Phone:847-695-3200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK04843Medicare ID - Type Unspecified