Provider Demographics
NPI:1811945405
Name:MCDONOUGH, DENNIS M (CRNA)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 NW SUMMERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-1921
Mailing Address - Country:US
Mailing Address - Phone:816-918-3225
Mailing Address - Fax:
Practice Address - Street 1:2313 NW SUMMERFIELD DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-1921
Practice Address - Country:US
Practice Address - Phone:816-918-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2013-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO061827367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO912682176Medicaid
MO540568508Medicaid
029516OtherAANA COUNCIL NUMBER
MO1811945405Medicaid
MO430044796Medicare PIN
MO540568508Medicaid
MOP00312297Medicare PIN
MOS550628Medicare PIN
MO1811945405Medicaid
P270000Medicare PIN