MEDICARE: CYMANTHIA KEESHA CONNELL M.D.

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	207Q00000X	Family Medicine Physician	68859	GA
2	207Q00000X	Family Medicine Physician	0440473	KS
3	261QP2300X	Primary Care Clinic/Center	207Q00000X	MO
4	207Q00000X	Family Medicine Physician	2013022689	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA1870009	OTHER	MO	MEDICARE PTAN

General Provider Information

NPI Number	:	1518278829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYMANTHIA KEESHA CONNELL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 742495
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-2495
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	81 NORTHSIDE DAWSON DR STE 100A
Second Line	:
City	:	DAWSONVILLE
State	:	GA
Zip	:	30534-7166
Country	:	US
Telephone Number	:	706-216-6000
Fax Number	:	706-216-6010

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

Provider Enumeration Date	:	07/01/2010
Last Update Date	:	02/26/2021

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