Basic Information
| Provider Information | |||||||||
| NPI: | 1225151558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | EARL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | ST. CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | ST. CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833221 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 50910 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 54869 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1225151558 | 05 | WI | MEDICAID | 1225151558 | 05 | MN | MEDICAID |