Provider Demographics
NPI:1366460800
Name:O'DONNELL, MICHAEL BRUCE SR (MA CCC-AUDIOLOGY)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:O'DONNELL
Suffix:SR
Gender:M
Credentials:MA CCC-AUDIOLOGY
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Mailing Address - Street 1:2525 FIFTH AVE SOUTH
Mailing Address - Street 2:#2
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1204
Mailing Address - Country:US
Mailing Address - Phone:906-786-5147
Mailing Address - Fax:906-786-0660
Practice Address - Street 1:2525 FIFTH AVE SOUTH
Practice Address - Street 2:SUITE 2
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1204
Practice Address - Country:US
Practice Address - Phone:906-786-5147
Practice Address - Fax:906-786-0660
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
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Provider Licenses
StateLicense IDTaxonomies
MI1601000117237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI64OB 126140OtherBC/BS OF MI
MI54OB 102580OtherBC/BS OF MI