Provider Demographics
NPI:1922049253
Name:CONNELLY, MARC B (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:B
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 1:4315 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5926
Mailing Address - Country:US
Mailing Address - Phone:907-563-2662
Mailing Address - Fax:
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:907-563-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD4852Medicaid
AK8EZ32JMedicare ID - Type Unspecified
AKMD4852Medicaid