Healthcare Provider Details

I. General information

NPI: 1659435899
Provider Name (Legal Business Name): PETER J. MCDONNELL M.D. SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 W COLLEGE DR
PALOS HEIGHTS IL
60463-1196
US

IV. Provider business mailing address

PO BOX 369
NEW LENOX IL
60451-0369
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-6605
  • Fax: 708-923-0705
Mailing address:
  • Phone: 815-463-0098
  • Fax: 815-462-4955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL

VIII. Authorized Official

Name: PETER J MCDONNELL
Title or Position: OWNER
Credential: MD SC
Phone: 708-923-6605