Provider Demographics
NPI:1689674608
Name:CONNERY, MARC (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:CONNERY
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:PO BOX 1076
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46308-1076
Mailing Address - Country:US
Mailing Address - Phone:219-662-3931
Mailing Address - Fax:219-663-6359
Practice Address - Street 1:170 BRACKEN PKWY
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6789
Practice Address - Country:US
Practice Address - Phone:219-942-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049420A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000354497OtherANTHEM
IN200330540Medicaid
IN000000354497OtherANTHEM
IN629990XMedicare ID - Type Unspecified