Healthcare Provider Details

I. General information

NPI: 1306888623
Provider Name (Legal Business Name): JOAN M CONNELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E ROSSER AVE
BISMARCK ND
58501
US

IV. Provider business mailing address

701 E ROSSER AVE
BISMARCK ND
58501
US

V. Phone/Fax

Practice location:
  • Phone: 701-751-9500
  • Fax: 701-751-9508
Mailing address:
  • Phone: 701-751-9500
  • Fax: 701-751-9508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9092
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11980
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: