MEDICARE: DR. MARY KARIN CONNOLLY MD

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	G57864	CA
2	207R00000X	Internal Medicine Physician	G57864	CA
3	207RR0500X	Rheumatology Physician	G57864	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942265772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY KARIN CONNOLLY MD

Provider Business Mailing Address
First Line	:	1635 DIVISADERO STREET, SUITE 625, BOX 1821
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94143-0001
Country	:	US
Telephone Number	:	415-476-4029
Fax Number	:	415-476-4150

Provider Business Practice Location Address
First Line	:	1701 DIVISADERO ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3011
Country	:	US
Telephone Number	:	415-353-7800
Fax Number	:	415-353-9654

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

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	08/28/2012

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