1750369419 NPI number — EDWARD A CONNOLLY MD

Table of content: EDWARD A CONNOLLY MD (NPI 1750369419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750369419 NPI number — EDWARD A CONNOLLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNOLLY
Provider First Name:
EDWARD
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1750369419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 VALLEY VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61265-6194
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-762-3621
Provider Business Mailing Address Fax Number:
309-762-3690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 VALLEY VIEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-6194
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-762-3621
Provider Business Practice Location Address Fax Number:
309-762-3690
Provider Enumeration Date:
01/04/2006

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: 207X00000X , with the licence number:  036093095 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 28464 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 036093095 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200029113 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1917237 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8121085 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: IA0194 . This is a "JOHN DEERE FAMILY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 18604 . This is a "MIDLANDS CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05353 . This is a "WELLMARK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 20170 . This is a "IA HEALTH SOLUTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 028389 . This is a "HEALTH ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 99717 . This is a "WELLMARK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 99728 . This is a "WELLMARK" identifier . This identifiers is of the category "OTHER".
  • Identifier: IL0174 . This is a "JOHN DEERE FAMILY" identifier . This identifiers is of the category "OTHER".




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