Provider Demographics
NPI:1578616819
Name:DONNELLY, JEROME VINCENT (DO)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:VINCENT
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-0900
Mailing Address - Country:US
Mailing Address - Phone:630-800-5646
Mailing Address - Fax:
Practice Address - Street 1:608 HILLGROVE AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1476
Practice Address - Country:US
Practice Address - Phone:630-800-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075925207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL499520Medicare ID - Type Unspecified
ILK36744Medicare PIN
ILK36743Medicare PIN
ILE18676Medicare UPIN