Provider Demographics
NPI:1730146069
Name:CONNELL, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:CONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7866
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36670-0866
Mailing Address - Country:US
Mailing Address - Phone:251-476-5443
Mailing Address - Fax:251-476-0116
Practice Address - Street 1:1613 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2247
Practice Address - Country:US
Practice Address - Phone:251-476-5443
Practice Address - Fax:251-476-0116
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL247372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009936421Medicaid
AL51003532OtherBC MONTCLAIR
AL009936423Medicaid
AL51003530OtherBC GREYSTONE
AL51003540OtherBC SYLACAUGA
AL51003538OtherBC SHELBY
AL009936422Medicaid
AL009936426Medicaid
AL009936424Medicaid
AL51003539OtherBC 280
ALI55253Medicare UPIN
AL51003538OtherBC SHELBY
AL009936426Medicaid