Healthcare Provider Details

I. General information

NPI: 1750555637
Provider Name (Legal Business Name): SCOTT VINCENT CONNELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE PEDIATRIC EMERGENCY MEDICINE FELLOWSHIP PROGRAM
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

9220 BOTHWELL ST APT 107
RALEIGH NC
27617-4393
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-7828
  • Fax:
Mailing address:
  • Phone: 856-313-9436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2010-00935
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2010-00935
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: