Provider Demographics
NPI:1457573941
Name:TOM SHI CONNALLY MD PC
Entity Type:Organization
Organization Name:TOM SHI CONNALLY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:SHI
Authorized Official - Last Name:CONNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-329-4102
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-307-6668
Mailing Address - Fax:405-307-6660
Practice Address - Street 1:500 EAST ROBINSON
Practice Address - Street 2:SUITE 2300
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6771
Practice Address - Country:US
Practice Address - Phone:405-329-4102
Practice Address - Fax:405-364-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23363208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200014890BMedicaid
OKP00072417OtherMEDICARE RAILROAD
OK200014890AMedicaid
OK800522290Medicare PIN
OKP00072417OtherMEDICARE RAILROAD
248324104Medicare ID - Type Unspecified
OK200014890BMedicaid