Provider Demographics
NPI:1740265834
Name:CONNOLLY, IRENE F (MD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:F
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 CONNABLE AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2212
Mailing Address - Country:US
Mailing Address - Phone:231-487-4086
Mailing Address - Fax:
Practice Address - Street 1:416 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2212
Practice Address - Country:US
Practice Address - Phone:231-487-4086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083187207R00000X, 207RH0003X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII23990Medicare UPIN