Provider Demographics
NPI:1841621877
Name:MICHAEL CONNELLY DC PLLC
Entity type:Organization
Organization Name:MICHAEL CONNELLY DC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DC
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-588-4000
Mailing Address - Street 1:9617 GRANBY ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503-1625
Mailing Address - Country:US
Mailing Address - Phone:757-588-4000
Mailing Address - Fax:757-588-4001
Practice Address - Street 1:9617 GRANBY ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23503-1625
Practice Address - Country:US
Practice Address - Phone:757-588-4000
Practice Address - Fax:757-588-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1790077576Medicare Oscar/Certification
VA1790077576Medicare UPIN
VA1790077576Medicare NSC
VA1790077576Medicare PIN