Healthcare Provider Details

I. General information

NPI: 1093971806
Provider Name (Legal Business Name): BRIAN DONOHUE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE SUITE 182
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

7447 W TALCOTT AVE SUITE 182
CHICAGO IL
60631-3745
US

V. Phone/Fax

Practice location:
  • Phone: 773-792-5155
  • Fax:
Mailing address:
  • Phone: 773-792-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036.125434
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.125434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: