Healthcare Provider Details

I. General information

NPI: 1700871969
Provider Name (Legal Business Name): JEREMY MCCONNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 11/29/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5717 21ST AVE WEST
BRADENTON FL
34209
US

IV. Provider business mailing address

5717 21ST AVE WEST
BRADENTON FL
34209
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-8383
  • Fax: 941-792-8484
Mailing address:
  • Phone: 941-792-8383
  • Fax: 941-792-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME83356
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberME83356
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License NumberME83356
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: