Provider Demographics
NPI:1609858984
Name:TRELLO, CONNIE A (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:A
Last Name:TRELLO
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 1:1350 WALTON WAY
Mailing Address - Street 2:3RD FL CRITICAL CARE MEDICINE
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2612
Mailing Address - Country:US
Mailing Address - Phone:706-774-5713
Mailing Address - Fax:706-774-5792
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:3RD FL CRITICAL CARE MEDICINE
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-5713
Practice Address - Fax:706-774-5792
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043495207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG43495Medicaid
GA000736766EMedicaid
GA000736766FMedicaid
GA000736766FMedicaid
SCG43495Medicaid