MEDICARE: THOMAS LEE DONNELLON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	4301052611	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073546883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS LEE DONNELLON M.D.

Provider Business Mailing Address
First Line	:	3050 COMMERCE DR
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3819
Country	:	US
Telephone Number	:	810-385-4441
Fax Number	:	810-385-1540

Provider Business Practice Location Address
First Line	:	120 N DELAWARE ST
Second Line	:
City	:	SANDUSKY
State	:	MI
Zip	:	48471-1009
Country	:	US
Telephone Number	:	810-648-3770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	06/05/2012

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