Provider Demographics
NPI:1659976082
Name:CONNOLLY DERMATOLOGY PHILADELPHIA LLC
Entity Type:Organization
Organization Name:CONNOLLY DERMATOLOGY PHILADELPHIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COYLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-926-8899
Mailing Address - Street 1:2099 NEW ALBANY RD
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-3534
Mailing Address - Country:US
Mailing Address - Phone:609-926-8899
Mailing Address - Fax:856-772-1997
Practice Address - Street 1:2418 E YORK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-3006
Practice Address - Country:US
Practice Address - Phone:609-926-8899
Practice Address - Fax:856-772-1997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COYLE S CONNOLLY DO PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty