Provider Demographics
NPI:1912951807
Name:O'CONNELL, MAURA P (DO)
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:P
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19020 FORT ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-6701
Mailing Address - Country:US
Mailing Address - Phone:734-362-5100
Mailing Address - Fax:734-362-5147
Practice Address - Street 1:19020 FORT ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-6701
Practice Address - Country:US
Practice Address - Phone:734-362-5100
Practice Address - Fax:734-362-5147
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015548208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H21076OtherBCBSM
MI9714265OtherCIGNA
MI16834OtherMCARE
MI4612263Medicaid
MI5101015548OtherPHYSICIAN LICENSE
MI139473OtherMERCY CARE CHOICES
MI7262536OtherAETNA
MICC33713OtherRR MEDICARE
MI2401684OtherUHC
MI7262536OtherAETNA
MI383268406OtherEIN TAX ID#
MIH79994Medicare UPIN