Provider Demographics
NPI:1710987615
Name:CONNELLY, MICHAEL C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
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 1:354 MERRIMACK STREET
Mailing Address - Street 2:BLDG. 1
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843
Mailing Address - Country:US
Mailing Address - Phone:978-687-2321
Mailing Address - Fax:978-722-7287
Practice Address - Street 1:354 MERRIMACK ST STE 1
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1755
Practice Address - Country:US
Practice Address - Phone:978-687-2321
Practice Address - Fax:978-722-7287
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58770208VP0014X, 207LP2900X
NH12648207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3073602Medicaid
NHUX7277Medicare PIN
MA3073602Medicaid
MAE56601Medicare UPIN
MAJ10002Medicare PIN
MAE56601Medicare UPIN