Provider Demographics
NPI:1841274636
Name:CONNELLY, MARY A (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:CONNELLY
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 1:1580 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5751
Mailing Address - Country:US
Mailing Address - Phone:920-445-7295
Mailing Address - Fax:
Practice Address - Street 1:1580 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5751
Practice Address - Country:US
Practice Address - Phone:920-445-7295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33056OtherLICENSE
WI33056OtherLICENSE
WIE86894Medicare UPIN