Provider Demographics
NPI:1841644358
Name:JEREMY D. MCCONNELL, MD, PA
Entity type:Organization
Organization Name:JEREMY D. MCCONNELL, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-404-0159
Mailing Address - Street 1:5717 21ST AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209
Mailing Address - Country:US
Mailing Address - Phone:941-792-8383
Mailing Address - Fax:941-792-8484
Practice Address - Street 1:5717 21ST AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209
Practice Address - Country:US
Practice Address - Phone:941-792-8383
Practice Address - Fax:941-792-8484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83356207Q00000X, 207QB0002X, 207QS1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNZ725OtherFL HF MEDICARE