Provider Demographics
NPI:1588026579
Name:CONNELL, ADAM (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:CONNELL
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 1:8810 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1935
Mailing Address - Country:US
Mailing Address - Phone:618-658-0639
Mailing Address - Fax:
Practice Address - Street 1:28 CHICK ST STE 100
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-2467
Practice Address - Country:US
Practice Address - Phone:618-524-8381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1524712084P0800X
IN01078829A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11018956AOtherIN TEMPORARY MEDICAL PERMIT