Healthcare Provider Details

I. General information

NPI: 1104841261
Provider Name (Legal Business Name): MICHAEL P CONNELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 S MIAMI AVE
MIAMI FL
33133-4253
US

IV. Provider business mailing address

5901 SW 74TH ST SUITE 202
MIAMI FL
33143-5165
US

V. Phone/Fax

Practice location:
  • Phone: 305-665-4614
  • Fax:
Mailing address:
  • Phone: 305-665-4614
  • Fax: 305-667-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME92360
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: