MEDICARE: KATHLEEN MCDONOUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	0929194	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11F35MC	OTHER	MN	BLUE CROSS/BLUE SHIELD
2	971465100	OTHER	MN	MEDICAL ASSISTANCE
3	HP29918	OTHER	MN	HEALTHPARTNERS
4	127557	OTHER	MN	UCARE
5	0700840	OTHER	MN	MEDICA
6	6982979	OTHER	MN	EVERCARE

General Provider Information

NPI Number	:	1851314470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MCDONOUGH

Provider Business Mailing Address
First Line	:	525 PORTLAND AVE
Second Line	:	MC: 952
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55415-1533
Country	:	US
Telephone Number	:	612-348-3033
Fax Number	:	612-348-7818

Provider Business Practice Location Address
First Line	:	525 PORTLAND AVE
Second Line	:	MC: 952
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55415-1533
Country	:	US
Telephone Number	:	612-348-3033
Fax Number	:	612-348-7818

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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Directions to “ KATHLEEN MCDONOUGH ” Practice Location

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