Healthcare Provider Details

I. General information

NPI: 1770876583
Provider Name (Legal Business Name): MARK STEPHEN CONNELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MICHIGAN AVE NW SUITE M4800
WASHINGTON DC
20010-2916
US

IV. Provider business mailing address

111 MICHIGAN AVE NW SUITE M4800
WASHINGTON DC
20010-2916
US

V. Phone/Fax

Practice location:
  • Phone: 202-476-6817
  • Fax:
Mailing address:
  • Phone: 202-476-6817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014-00895
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD043066
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: