Provider Demographics
NPI:1245019801
Name:CONNELL, ELIJAH
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:CONNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2634 CALVARY RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-6616
Mailing Address - Country:US
Mailing Address - Phone:443-617-1575
Mailing Address - Fax:
Practice Address - Street 1:5215 LOUGHBORO RD NW STE 200
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-2625
Practice Address - Country:US
Practice Address - Phone:202-787-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty