Provider Demographics
NPI:1023010279
Name:CONNOLLY, MATTHEW JAMES (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:560 S LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3405
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-817-7848
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244122213EP1101X, 213E00000X, 213ES0103X
KY00180213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY480034467OtherRAILROAD MEDICARE
KYCB8861OtherRAILROAD MEDICARE
KY80001803OtherMEDICAID DME
KY000000249598OtherANTHEM
KY90008962OtherMEDICAID DME
KY80001803Medicaid
KY90008962OtherMEDICAID DME
KY480034467OtherRAILROAD MEDICARE
KY0389209Medicare PIN
KYCB8861OtherRAILROAD MEDICARE
KY000000249598OtherANTHEM
KY0428850006Medicare NSC