Provider Demographics
NPI:1477546208
Name:MCCONNELL, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:MCCONNELL
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 1:500 W. FORT ST.
Mailing Address - Street 2:MAIL CODE 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6241
Mailing Address - Country:US
Mailing Address - Phone:208-422-1325
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W. FORT ST.
Practice Address - Street 2:MAIL CODE 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6241
Practice Address - Country:US
Practice Address - Phone:208-422-1325
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM93262080P0203X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000459Medicare PIN