Basic Information
| Provider Information | |||||||||
| NPI: | 1912913963 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DONAHUE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2867 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366522867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908158 | ||||||||
| FaxNumber: | 2516908853 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 N BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366035827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516908158 | ||||||||
| FaxNumber: | 2516908853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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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 | 208000000X | 13856 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 631300093 | 05 | AL | MEDICAID | 011846 | 01 | AL | MEDICARE GROUP NUMBER | OTHER | 1063439065 | 01 | AL | SITE NPI MCARE GROUP PAYEE | OTHER |