Provider Demographics
NPI:1083031975
Name:CONNOLLY, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 27TH PL S
Mailing Address - Street 2:APT. 14
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-2567
Mailing Address - Country:US
Mailing Address - Phone:205-934-9767
Mailing Address - Fax:205-934-3993
Practice Address - Street 1:1720 2ND AVNEUE S
Practice Address - Street 2:BDB 563
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294-0012
Practice Address - Country:US
Practice Address - Phone:205-934-9767
Practice Address - Fax:205-934-3993
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL3980F174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist