Healthcare Provider Details

I. General information

NPI: 1689674608
Provider Name (Legal Business Name): MARC CONNERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 BRACKEN PKWY
HOBART IN
46342-6789
US

IV. Provider business mailing address

PO BOX 1076
CROWN POINT IN
46308-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-942-7156
  • Fax:
Mailing address:
  • Phone: 219-662-3931
  • Fax: 219-663-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01049420A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: