Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 005262 | IA |
N | 2251X0800X | Physical Therapist - Orthopedic | 1768PT | MT |
NPI | 1023214962 |
---|---|
Provider Name | Troy Michael Mcdonough |
First Address | Oak Brook, IL 60523-8813 |
Second Address | Ames, IA 50010-5400 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2007 |
Last Update Date | 05/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0000344097 | (05) | MT |
000060776 | BLUE CROSS FOR SEELY LAKE (01) | MT |
00006175 | BLUE CROSS (01) | MT |