Healthcare Provider Details

I. General information

NPI: 1225151558
Provider Name (Legal Business Name): PATRICK EARL MCDONOUGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 STATE STREET
ST. CROIX FALLS WI
54024
US

IV. Provider business mailing address

235 STATE STREET
ST. CROIX FALLS WI
54024
US

V. Phone/Fax

Practice location:
  • Phone: 715-483-3221
  • Fax: 715-483-0507
Mailing address:
  • Phone: 715-483-3221
  • Fax: 715-483-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number50910
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number54869
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: