Basic Information
| Provider Information | |||||||||
| NPI: | 1043224041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY MCDONALD MD SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3420 JACKSON ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549018144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204262211 | ||||||||
| FaxNumber: | 9204262231 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 W 9TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202230490 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 10/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | LENZ | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9204262211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 28027020 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 21299800 | 05 | WI | MEDICAID |