Provider Demographics
NPI:1982631446
Name:CONOLLY, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:CONOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 LAND RE WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-1735
Mailing Address - Country:US
Mailing Address - Phone:585-368-6620
Mailing Address - Fax:585-368-6621
Practice Address - Street 1:4 LAND RE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1735
Practice Address - Country:US
Practice Address - Phone:585-368-6620
Practice Address - Fax:585-368-6621
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01685294Medicaid
G09519Medicare UPIN
000911405002OtherHEALTH NOW
5997119OtherGHI
NY01685294Medicaid
P010195431OtherBLUE SHIELD
101512BFOtherPREFERRED CARE
1954312WCFPOtherWORKERS COMP
0508644OtherAETNA
RA0283Medicare ID - Type Unspecified