Provider Demographics
NPI:1104868900
Name:MCDONNELL, ROBERT (MSPT, MDT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MCDONNELL
Suffix:
Gender:M
Credentials:MSPT, MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:591 MEMORIAL DR
Practice Address - Street 2:SUITE H
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-5024
Practice Address - Country:US
Practice Address - Phone:413-331-1625
Practice Address - Fax:413-377-3178
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001531225100000X
PAPT014034L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000037716Medicaid
292670OtherMAMSI
5070-0091OtherNCA
1104868900OtherCHAMPUS
1039897OtherPABS
11416967OtherCAQH
PA1309897OtherPABS
2003135000OtherIBC
92839701OtherCAREFIRST
1039897OtherPABS
P00398586Medicare PIN
DEG02378A14Medicare PIN