Provider Demographics
NPI:1770682643
Name:CONNELL, MARK OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:OWEN
Last Name:CONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-297-4104
Practice Address - Fax:570-297-2066
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036027E208600000X
VA0101253604208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010468730001Medicaid
VA1770682643Medicaid
VAVV9245AMedicare PIN