Provider Demographics
NPI:1831267145
Name:MARY ANN MCDONNELL MD PC
Entity type:Organization
Organization Name:MARY ANN MCDONNELL MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MD PC
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-628-3636
Mailing Address - Street 1:301 NORTH 200 EAST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-628-3636
Mailing Address - Fax:435-634-9216
Practice Address - Street 1:301 NORTH 200 EAST
Practice Address - Street 2:SUITE 1D
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-628-3636
Practice Address - Fax:435-634-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1583921205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT516523696034Medicaid
UT516523696034Medicaid