Provider Demographics
NPI:1336154210
Name:CONNOLLY, MASON (DC)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138C EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1882
Mailing Address - Country:US
Mailing Address - Phone:618-622-1793
Mailing Address - Fax:618-622-1795
Practice Address - Street 1:138C EAGLE DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1882
Practice Address - Country:US
Practice Address - Phone:618-622-1793
Practice Address - Fax:618-622-1795
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009170111N00000X
IL083-009170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08227539OtherBLUECROSS/ BLUE SHIELD
IL08227539OtherBLUECROSS/ BLUE SHIELD
624470Medicare ID - Type Unspecified