Basic Information
| Provider Information | |||||||||
| NPI: | 1790742849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | # L-3652 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432606052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837927 | ||||||||
| FaxNumber: | 7403837942 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837950 | ||||||||
| FaxNumber: | 7403837097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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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 | 35081423M | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2333853 | 05 | OH | MEDICAID | 000000233026 | 01 | OH | ANTHEM | OTHER | 311098079 | 01 | TAX ID | OTHER | 353077 | 01 | SUBMITTER NO | OTHER | 7794409 | 01 | AETNA | OTHER | 311098079 | 01 | PPO NEXT | OTHER | 311098079 | 01 | CIGNA | OTHER | 020052624 | 01 | TRAVELERS MEDICARE | OTHER | 1402423 | 01 | UHC | OTHER |