Provider Demographics
NPI:1790865285
Name:CONNOLLY, PHILIP PETER (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:PETER
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7025C MANCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22310-3227
Mailing Address - Country:US
Mailing Address - Phone:703-719-7302
Mailing Address - Fax:703-719-9462
Practice Address - Street 1:7025C MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3227
Practice Address - Country:US
Practice Address - Phone:703-719-7302
Practice Address - Fax:703-719-9462
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001006111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA026990OtherANTHEM
VAG884OtherCAREFIRST BC/BS
VAG884OtherCAREFIRST BC/BS
VAG01662S01Medicare UPIN