Provider Demographics
NPI:1558535559
Name:CONNOLLY, MARY J (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FODEN RD, WEST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN ROAD, EAST
Practice Address - Street 2:SUITE 203
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-874-1489
Practice Address - Fax:207-523-8590
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18621207Q00000X
MA232521208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH32000562Medicaid
MEP00999149Medicare PIN
ME001967702Medicare PIN
ME001967703Medicare PIN
ME001967704Medicare PIN
MEP00965878Medicare PIN
ME001967701Medicare PIN
ME001967706Medicare PIN
ME001967705Medicare PIN