Provider Demographics
NPI:1336137330
Name:O'DONNELL, PATRICK GILBERT (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:GILBERT
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PATRICK
Other - Middle Name:GARY
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1945 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3943
Mailing Address - Country:US
Mailing Address - Phone:217-492-2000
Mailing Address - Fax:
Practice Address - Street 1:1945 S SPRING ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3943
Practice Address - Country:US
Practice Address - Phone:217-492-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361089292084P0800X
IL036-1089292084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108929Medicaid
ILL98931Medicare UPIN
IL036108929Medicaid