Basic Information
| Provider Information | |||||||||
| NPI: | 1023214962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M.S.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605238813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1215 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159564095 | ||||||||
| FaxNumber: | 5159564093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 08/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 1768PT | MT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | 005262 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 00006175 | 01 | MT | BLUE CROSS | OTHER | 0000344097 | 05 | MT | MEDICAID | 000060776 | 01 | MT | BLUE CROSS FOR SEELY LAKE | OTHER |