Provider Demographics
NPI:1124284922
Name:DONNELLY, ERIC DONALD (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DONALD
Last Name:DONNELLY
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 1:4457 N MAGNOLIA AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-6298
Mailing Address - Country:US
Mailing Address - Phone:319-360-2095
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:GALTER PAVILION, LC-178
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-926-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250540362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology