Provider Demographics
NPI:1114312196
Name:CONNOLLY, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
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 1:409 N PACIFIC COAST HWY STE 166
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2870
Mailing Address - Country:US
Mailing Address - Phone:805-660-3510
Mailing Address - Fax:866-225-3208
Practice Address - Street 1:409 N PACIFIC COAST HWY STE 166
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2870
Practice Address - Country:US
Practice Address - Phone:805-660-3510
Practice Address - Fax:866-225-3208
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic