Provider Demographics
NPI:1104815208
Name:CONNOLLY, BRIAN A (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:189 TOWNSEND ST
Mailing Address - Street 2:STE 300
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-6008
Mailing Address - Country:US
Mailing Address - Phone:248-642-3737
Mailing Address - Fax:248-642-1083
Practice Address - Street 1:189 TOWNSEND ST
Practice Address - Street 2:STE 300
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6008
Practice Address - Country:US
Practice Address - Phone:248-642-3737
Practice Address - Fax:248-642-1083
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010335022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
0637632Medicare ID - Type Unspecified
B47219Medicare UPIN