Provider Demographics
NPI:1750369419
Name:CONNOLLY, EDWARD A (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:CONNOLLY
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 1:520 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6194
Mailing Address - Country:US
Mailing Address - Phone:309-762-3621
Mailing Address - Fax:309-762-3690
Practice Address - Street 1:520 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6194
Practice Address - Country:US
Practice Address - Phone:309-762-3621
Practice Address - Fax:309-762-3690
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093095207X00000X
IA28464207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093095Medicaid
200029113OtherRR MEDICARE
IA1917237Medicaid
IL8121085OtherBCBS
IA0194OtherJOHN DEERE FAMILY
18604OtherMIDLANDS CHOICE
05353OtherWELLMARK
20170OtherIA HEALTH SOLUTIONS
028389OtherHEALTH ALLIANCE
99717OtherWELLMARK
99728OtherWELLMARK
IL0174OtherJOHN DEERE FAMILY
18604OtherMIDLANDS CHOICE
G17107Medicare UPIN
20170OtherIA HEALTH SOLUTIONS