Provider Demographics
NPI:1457321978
Name:CONNELLY, CHRISTOPHER SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SCOTT
Last Name:CONNELLY
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 MEDICAL PARK DR
Practice Address - Street 2:STE 202
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1902
Practice Address - Country:US
Practice Address - Phone:704-403-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700218207RS0012X, 2084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2250023BOtherMEDICARE PTAN
NC1457321978Medicaid
NC1120KOtherBCBSNC
NC891120KMedicaid
NC79990OtherMEDCOST
NC27634OtherPARTNERS MEDICARE CHOICE
NC3426137OtherCIGNA
NC5644651OtherAETNA
NC79990OtherMEDCOST
NCNCB722AMedicare PIN