MEDICARE: DR. COYLE S CONNOLLY D.O. PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	25MB06289800	NJ

General Provider Information

NPI Number	:	1386601433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COYLE S CONNOLLY D.O. PA

Provider Business Mailing Address
First Line	:	2099 NEW ALBANY RD
Second Line	:
City	:	CINNAMINSON
State	:	NJ
Zip	:	08077-3534
Country	:	US
Telephone Number	:	609-926-8899
Fax Number	:	856-772-1997

Provider Business Practice Location Address
First Line	:	2106 NEW RD STE D4
Second Line	:
City	:	LINWOOD
State	:	NJ
Zip	:	08221-1050
Country	:	US
Telephone Number	:	609-926-8899
Fax Number	:	609-926-6474

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/09/2021

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