Provider Demographics
NPI:1689629677
Name:CONNELLY, STEVEN N (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:N
Last Name:CONNELLY
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:FILE 50421
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:800-793-3529
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029817207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8938302OtherWA CRIME VICTIM
CO8227OtherREGENCE BS
184570OtherWA L&I
WA8148926Medicaid
E76665OtherGROUP HEALTH
8802602Medicare PIN
E76665OtherGROUP HEALTH
CO8227OtherREGENCE BS
G8802608Medicare PIN
P00220717Medicare PIN