Healthcare Provider Details

I. General information

NPI: 1033162839
Provider Name (Legal Business Name): MARK M. CONNOLLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2913 N COMMONWEALTH AVE 5TH FLOOR
CHICAGO IL
60657-6211
US

IV. Provider business mailing address

PO BOX 597995
CHICAGO IL
60659-7995
US

V. Phone/Fax

Practice location:
  • Phone: 773-472-3427
  • Fax: 773-472-8561
Mailing address:
  • Phone: 773-472-3427
  • Fax: 773-472-8561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number036063941
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: