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MCDONOUGH MEDICAL GROUP
Complete NPI Record 1396055869
Pathology - Anatomic Pathology & Clinical Pathology in Macomb, IL

NPI Status: Active since October 18, 2010

Contact Information

525 E GRANT STREET
MACOMB, IL
ZIP 61455
Phone: (309) 833-4101
Fax: (309) 836-1534

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider Other Organization Name
  6. Provider Other Organization Name Type Code
  7. Provider First Line Business Mailing Address
  8. Provider Business Mailing Address City Name
  9. Provider Business Mailing Address State Name
  10. Provider Business Mailing Address Postal Code
  11. Provider Business Mailing Address Country Code If outside U S
  12. Provider Business Mailing Address Telephone Number
  13. Provider Business Mailing Address Fax Number
  14. Provider First Line Business Practice Location Address
  15. Provider Business Practice Location Address City Name
  16. Provider Business Practice Location Address State Name
  17. Provider Business Practice Location Address Postal Code
  18. Provider Business Practice Location Address Country Code If outside U S
  19. Provider Business Practice Location Address Telephone Number
  20. Provider Business Practice Location Address Fax Number
  21. Provider Enumeration Date
  22. Last Update Date
  23. Authorized Official Last Name
  24. Authorized Official First Name
  25. Authorized Official Middle Name
  26. Authorized Official Title or Position
  27. Authorized Official Telephone Number
  28. Healthcare Provider Taxonomy Code 1
  29. Provider License Number 1
  30. Provider License Number State Code 1
  31. Healthcare Provider Primary Taxonomy Switch 1
  32. Is Organization Subpart
  33. Healthcare Provider Taxonomy Group 1

Complete NPI Dataset

This page represents the complete record for NPI 1396055869. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1396055869
The last name of the provider. If the provider is an individual, this is the legal name.
Entity Type Code: 2
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: UNAVAIL
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Other Organization Name: MCDONOUGH MEDICAL GROUP
Other name by which the organization provider is or has been known.
Provider Other Organization Name Type Code: 3
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
Provider First Line Business Mailing Address: 525 E GRANT STREET
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other.
Provider Business Mailing Address City Name: MACOMB
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: IL
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code: 614553313
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S : US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address Telephone Number: 3098334101
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider Business Mailing Address Fax Number: 3098361534
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address fax number’’.
Provider First Line Business Practice Location Address: 525 E GRANT STREET
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: MACOMB
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: IL
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 614553313
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 3098334101
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 3098361534
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 10/18/2010
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 10/18/2010
The date that a record was last updated or changed.
Authorized Official Last Name: HOPPER
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: STEPHEN
The first name of the authorized official.
Authorized Official Middle Name: R
The middle name of the authorized official.
Authorized Official Title or Position: CEO
The title or position of the authorized official.
Authorized Official Telephone Number: 3098334101
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Healthcare Provider Taxonomy Code 1: 207ZP0102X
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider License Number 1: 0001438
The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
Provider License Number State Code 1: IL
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number.
Healthcare Provider Primary Taxonomy Switch 1: Y
Is Organization Subpart: N
Healthcare Provider Taxonomy Group 1: 193400000X SINGLE SPECIALTY GROUP