Provider Demographics
NPI:1144220435
Name:CONNELLY, KEVIN P (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8316 CHARING LN
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1602 SKIPWITH RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-5205
Practice Address - Country:US
Practice Address - Phone:804-200-7575
Practice Address - Fax:804-200-7069
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037028207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006706029Medicaid
VA006706100Medicaid
VA010210941Medicaid
VA010376963Medicaid
VA006706100Medicaid
VA010376963Medicaid
VA370001135Medicare PIN
VA012631V20Medicare PIN