Healthcare Provider Details

I. General information

NPI: 1851412779
Provider Name (Legal Business Name): KRISTOPHER MICHAEL MCDONOUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 N 129TH INFANTRY DR SUITE #400
JOLIET IL
60435-3171
US

IV. Provider business mailing address

903 N 129TH INFANTRY DR SUITE #400
JOLIET IL
60435-3171
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-2653
  • Fax: 815-744-3232
Mailing address:
  • Phone: 815-725-2653
  • Fax: 815-744-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number36113500
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: