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General NPI Number Information
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NPI Number | 1578616819
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Entity Type | Individual
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Provider Name | JEROME VINCENT DONNELLY DO
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Gender | Male
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 02/20/2014
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Provider Practice Location Address
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Address Line | 608 HILLGROVE AVE
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City | WESTERN SPRINGS
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State | IL
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Zip | 60558-1476
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Country | US
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Telephone | 630-800-5646
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 900
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City | LA GRANGE
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State | IL
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Zip | 60525-0900
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Country | US
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Telephone | 630-800-5646
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 036075925
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License Number State | IL
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