=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053501320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERENCE J MCDONNELL MD PROFESSIONAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2007
-----------------------------------------------------
Last Update Date | 10/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2999 REGENT STREET SUITE 710
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94705-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-841-1266
-----------------------------------------------------
Fax | 510-841-0423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2999 REGENT STREET SUITE 710
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94705-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-841-1266
-----------------------------------------------------
Fax | 510-841-0423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TERENCE J MCDONNELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 510-841-1266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | C326600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------