Provider Demographics
NPI:1124194931
Name:CONNELLY, STEPHEN J (PT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:J
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:2516 E. DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2097
Practice Address - Country:US
Practice Address - Phone:260-490-4800
Practice Address - Fax:260-497-8399
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005430A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INN235814OtherHARMONY
IN156546OtherMEDICARE
IN000000197330OtherANTHEM BCBS
IN4423623OtherAETNA
IN1424OtherPHP
IN200362960AMedicaid