Provider Demographics
NPI:1659435899
Name:PETER J. MCDONNELL M.D. SC
Entity Type:Organization
Organization Name:PETER J. MCDONNELL M.D. SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD SC
Authorized Official - Phone:708-923-6605
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-0369
Mailing Address - Country:US
Mailing Address - Phone:815-463-0098
Mailing Address - Fax:815-462-4955
Practice Address - Street 1:7530 W COLLEGE DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1196
Practice Address - Country:US
Practice Address - Phone:708-923-6605
Practice Address - Fax:708-923-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL906231Medicare ID - Type Unspecified
ILE19022Medicare UPIN