Provider Demographics
NPI:1356337737
Name:CONNOLLY, WILLIAM S (DO)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 WASHINGTON ST
Mailing Address - Street 2:BOX 9
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3655
Mailing Address - Country:US
Mailing Address - Phone:570-621-5018
Mailing Address - Fax:570-621-5806
Practice Address - Street 1:420 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3625
Practice Address - Country:US
Practice Address - Phone:570-621-5325
Practice Address - Fax:570-621-5806
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002643L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009230310005Medicaid
PAB35244Medicare UPIN
PA082760GUJMedicare ID - Type Unspecified