Healthcare Provider Details

I. General information

NPI: 1114972783
Provider Name (Legal Business Name): MARY OLSEN CONNELLY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 E GRANT RD
TUCSON AZ
85712-2805
US

IV. Provider business mailing address

1810 E SENECA ST
TUCSON AZ
85719-3747
US

V. Phone/Fax

Practice location:
  • Phone: 520-795-8188
  • Fax:
Mailing address:
  • Phone: 520-318-0027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number68491
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier937295
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: