Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | MD24053 | MO |
NPI | 1356476071 |
---|---|
Provider Name | Mr. Thomas M Macdonnell |
First Address | Marshfield, MO 65706-8253 |
Second Address | Marshfield, MO 65706-8253 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A11462 | (02) | MO |