Provider Demographics
NPI:1033162839
Name:CONNOLLY, MARK M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 597995
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-7995
Mailing Address - Country:US
Mailing Address - Phone:773-472-3427
Mailing Address - Fax:773-472-8561
Practice Address - Street 1:2913 N COMMONWEALTH AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6211
Practice Address - Country:US
Practice Address - Phone:773-472-3427
Practice Address - Fax:773-472-8561
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360639412086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063941Medicaid
ILP00261094OtherMEDICARE RAILROAD PART B
IL0001618161OtherBCBS OF IL
IL790210Medicare ID - Type UnspecifiedMEDICARE ID
ILC44346Medicare UPIN