Basic Information
| Provider Information | |||||||||
| NPI: | 1669791893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 LAKE COOK RD STE M | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479454550 | ||||||||
| FaxNumber: | 8479488103 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 N AIRLITE ST | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476958850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 07/30/2018 | ||||||||
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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 | 2085R0202X | 274865 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036.139705 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | Q4200 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 036.139705 | 01 | IL | MEDICAL LICENSE | OTHER |