Provider Demographics
NPI:1558361899
Name:CONNERLY, BRANDON KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:KEITH
Last Name:CONNERLY
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 38
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0038
Mailing Address - Country:US
Mailing Address - Phone:812-738-4251
Mailing Address - Fax:
Practice Address - Street 1:1601 E WHISKEY RUN RD NE
Practice Address - Street 2:
Practice Address - City:NEW SALISBURY
Practice Address - State:IN
Practice Address - Zip Code:47161-9345
Practice Address - Country:US
Practice Address - Phone:812-347-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058296A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200459910Medicaid
OH2475101Medicaid
IN000000322352OtherBC/BS #
IN168790JMedicare ID - Type UnspecifiedMEDICARE #
OH2475101Medicaid