Provider Demographics
NPI:1043490097
Name:KILLORY, BRENDAN DYER (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:DYER
Last Name:KILLORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 709
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-696-2290
Mailing Address - Fax:860-696-2280
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 709
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-696-2290
Practice Address - Fax:860-696-2280
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ80789207T00000X
CT049554207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ80789OtherTRAINING PERMIT
CT7432716OtherGREAT WEST HEALTHCARE
CT049554OtherCONNECTICARE
CT1043490097Medicaid
CTP4362821OtherOXFORD
CT7432716OtherCIGNA
CT1043490097Medicare PIN