Provider Demographics
NPI:1275020349
Name:MCDONOUGH, GREGORY L
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 220
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4405
Mailing Address - Country:US
Mailing Address - Phone:215-955-8465
Mailing Address - Fax:215-955-2516
Practice Address - Street 1:833 CHESTNUT ST STE 220
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4405
Practice Address - Country:US
Practice Address - Phone:215-955-8465
Practice Address - Fax:215-955-2516
Is Sole Proprietor?:No
Enumeration Date:2018-04-15
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT215085207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine