Provider Demographics
NPI:1144217951
Name:CONNELLY, PATRICK J (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73383
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0002
Mailing Address - Country:US
Mailing Address - Phone:800-777-2931
Mailing Address - Fax:
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045963207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C02843Medicare UPIN