Provider Demographics
NPI:1619119138
Name:MCDONNELL, GREGORY MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:MICHAEL
Last Name:MCDONNELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28803 DAHLIA DR NW
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-6331
Mailing Address - Country:US
Mailing Address - Phone:763-452-0171
Mailing Address - Fax:763-452-0171
Practice Address - Street 1:3220 BRIDGE ST NW STE 108
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:MN
Practice Address - Zip Code:55070-8631
Practice Address - Country:US
Practice Address - Phone:763-452-0171
Practice Address - Fax:513-912-0776
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4112111N00000X
OHACPU-00177171100000X
MN1074171100000X
MN4979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3138456Medicaid