1013121474 NPI number — MR. EUGENE MARK CONNOLLY RPA-C

Table of content: MR. EUGENE MARK CONNOLLY RPA-C (NPI 1013121474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013121474 NPI number — MR. EUGENE MARK CONNOLLY RPA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNOLLY
Provider First Name:
EUGENE
Provider Middle Name:
MARK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONNOLLY
Provider Other First Name:
GENE
Provider Other Middle Name:
MARK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPA C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1013121474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
57 HAMPTON RD
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
SOUTHAMPTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11968-4973
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-283-1126
Provider Business Mailing Address Fax Number:
631-283-7496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
518 MONTAUK HWY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
AMAGANSETT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11930-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-267-5373
Provider Business Practice Location Address Fax Number:
631-267-5376
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  010108 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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