Basic Information
Provider Information | |||||||||
NPI: | 1831107671 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DONNELLY | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO FACOS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
Address2: | BELOIT HEALTH SYSTEM INC. | ||||||||
City: | BELOIT | ||||||||
State: | WI | ||||||||
PostalCode: | 535111842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083642200 | ||||||||
FaxNumber: | 6083642705 | ||||||||
Practice Location | |||||||||
Address1: | 1905 E. HUEBBE PARKWAY | ||||||||
Address2: | BELOIT HEALTH SYSTEM INC. | ||||||||
City: | BELOIT | ||||||||
State: | WI | ||||||||
PostalCode: | 535111842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083642200 | ||||||||
FaxNumber: | 6083642705 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2006 | ||||||||
LastUpdateDate: | 10/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 33488021 | WI | Y |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | 036-075916 | IL | N |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 10631 | 01 |   | DEAN HEALTH PLAN HMO | OTHER | 1831107671 | 05 | WI |   | MEDICAID |