Healthcare Provider Details

I. General information

NPI: 1255310330
Provider Name (Legal Business Name): MICHAEL GERARD DONNELLY SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 MAIN ST BUILDING A, SUITE 2
CHESTER NJ
07930-2669
US

IV. Provider business mailing address

4 GLENBROOK DR
MENDHAM NJ
07945-2306
US

V. Phone/Fax

Practice location:
  • Phone: 973-879-4941
  • Fax:
Mailing address:
  • Phone: 973-543-7966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number25MA05194300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number186643
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD428130
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: