Provider Demographics
NPI:1831107671
Name:DONNELLY, MICHAEL A (DO FACOS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:DO FACOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC.
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-364-2705
Practice Address - Street 1:1905 E. HUEBBE PARKWAY
Practice Address - Street 2:BELOIT HEALTH SYSTEM INC.
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2200
Practice Address - Fax:608-364-2705
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI33488021208800000X
IL036-075916208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10631OtherDEAN HEALTH PLAN HMO
WI1831107671Medicaid
WI543300087Medicare PIN
WI1831107671Medicaid