Provider Demographics
NPI:1376552430
Name:CONNELL, GEORGE THOMAS (PT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:THOMAS
Last Name:CONNELL
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 1:17 LANE DR
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:VT
Mailing Address - Zip Code:05345-9587
Mailing Address - Country:US
Mailing Address - Phone:802-365-7269
Mailing Address - Fax:802-365-7269
Practice Address - Street 1:17 LANE DR
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:VT
Practice Address - Zip Code:05345-9587
Practice Address - Country:US
Practice Address - Phone:802-365-7269
Practice Address - Fax:802-365-7269
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0400003607225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT101937Medicaid
VT00068291OtherBCBS
4128427OtherMVP
VTVN3546Medicare ID - Type Unspecified