Basic Information
| Provider Information | |||||||||
| NPI: | 1417069089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4535 NORTHERN SKY DR | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585038538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017123000 | ||||||||
| FaxNumber: | 7017123005 | ||||||||
| Practice Location | |||||||||
| Address1: | 4535 NORTHERN SKY DR | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585038538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017123000 | ||||||||
| FaxNumber: | 7017123005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7470 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1454905 | 05 | ND | MEDICAID | 18975 | 05 | ND | MEDICAID |