Provider Demographics
NPI:1124096482
Name:MCDONNELL, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MCDONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2576
Mailing Address - Country:US
Mailing Address - Phone:309-671-8503
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF INTERNAL MEDICINE
Practice Address - Street 2:530 NE GLEN OAK
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0104OtherJOHN DEERE
IL07215036OtherBCBS
ILIL0104OtherJOHN DEERE
ILL98663Medicare ID - Type UnspecifiedINDIVIDUAL #
IL07215036OtherBCBS
ILP00019060Medicare ID - Type UnspecifiedRR INDIVIDUAL
ILCA4079Medicare ID - Type UnspecifiedRR GROUP #
IL639810Medicare ID - Type UnspecifiedMEDICARE