1124194931 NPI number — MR. STEPHEN J CONNELLY PT

Table of content: MR. STEPHEN J CONNELLY PT (NPI 1124194931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124194931 NPI number — MR. STEPHEN J CONNELLY PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNELLY
Provider First Name:
STEPHEN
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124194931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4251 LAHMEYER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46815-5676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-432-4700
Provider Business Mailing Address Fax Number:
260-459-9262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2516 E. DUPONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-2097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-490-4800
Provider Business Practice Location Address Fax Number:
260-497-8399
Provider Enumeration Date:
11/27/2006

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: 225100000X , with the licence number:  05005430A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: N235814 . This is a "HARMONY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 156546 . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000197330 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4423623 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1424 . This is a "PHP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200362960A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com