Healthcare Provider Details

I. General information

NPI: 1801914361
Provider Name (Legal Business Name): JOHN CONNOLLY RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E WALNUT ST
BLOOMINGTON IL
61701-3244
US

IV. Provider business mailing address

610 S CLAYTON ST
BLOOMINGTON IL
61701-5449
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-8004
  • Fax:
Mailing address:
  • Phone: 847-441-5593
  • Fax: 847-441-0734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: