Basic Information
| Provider Information | |||||||||
| NPI: | 1407992738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONNELLY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20110 GOVERNORS HWY | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FIELDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087477960 | ||||||||
| FaxNumber: | 7085033993 | ||||||||
| Practice Location | |||||||||
| Address1: | 9550 W 167TH ST | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604675561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088734500 | ||||||||
| FaxNumber: | 7088734505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208600000X | IL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2476959 | 05 | PA | MEDICAID |