Provider Demographics
NPI:1255429353
Name:CONNELLY CARE PLLC
Entity type:Organization
Organization Name:CONNELLY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-537-9844
Mailing Address - Street 1:5300 S SUTTER DR
Mailing Address - Street 2:STE 11
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-8054
Mailing Address - Country:US
Mailing Address - Phone:928-537-9844
Mailing Address - Fax:928-537-4437
Practice Address - Street 1:5300 S SUTTER DR
Practice Address - Street 2:STE 11
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-8054
Practice Address - Country:US
Practice Address - Phone:928-537-9844
Practice Address - Fax:928-537-4437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34632174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ465272Medicaid
AZZ111298Medicare UPIN