Provider Demographics
NPI:1245259944
Name:MCCONNELL, STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MCCONNELL
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 1:2825 BARRY KNOLL WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1944
Mailing Address - Country:US
Mailing Address - Phone:260-627-5524
Mailing Address - Fax:260-637-7454
Practice Address - Street 1:2825 BARRY KNOLL WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1944
Practice Address - Country:US
Practice Address - Phone:260-627-5524
Practice Address - Fax:260-637-7454
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038058207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100331110Medicaid
E18717Medicare UPIN
IN138420AAMedicare ID - Type Unspecified
IN178650HMedicare ID - Type Unspecified
IN295910BBBMedicare ID - Type Unspecified
IN142520NMedicare ID - Type Unspecified