Provider Demographics
NPI:1730338393
Name:MCDONELL, MATTHEW MICHAEL (NP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:MCDONELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2205 JOLLY RD
Practice Address - Street 2:SUITE B
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3983
Practice Address - Country:US
Practice Address - Phone:517-347-4085
Practice Address - Fax:517-347-4170
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704249339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC37626087Medicare PIN