Provider Demographics
NPI:1073731808
Name:CONNOLLY, KEVIN M (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 JORIE BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2213
Mailing Address - Country:US
Mailing Address - Phone:630-574-0422
Mailing Address - Fax:630-574-1002
Practice Address - Street 1:900 JORIE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2213
Practice Address - Country:US
Practice Address - Phone:630-574-0422
Practice Address - Fax:630-574-1002
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2013-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006475111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211829Medicare ID - Type UnspecifiedPROVIDER NUMBER