Provider Demographics
NPI:1912929084
Name:CONNOR, GERALDINE
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:CONNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SENEY
Mailing Address - State:MI
Mailing Address - Zip Code:49883-0038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14460 ROSS LAKE ROAD
Practice Address - Street 2:
Practice Address - City:SENEY
Practice Address - State:MI
Practice Address - Zip Code:49883
Practice Address - Country:US
Practice Address - Phone:906-202-1898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650G710060OtherBLUE CROSS BLUE SHIELD MI
MIP21530001Medicare PIN
MI650G710060OtherBLUE CROSS BLUE SHIELD MI