Healthcare Provider Details

I. General information

NPI: 1053367516
Provider Name (Legal Business Name): COYLE S CONNOLLY DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 NEW RD SUITE D4
LINWOOD NJ
08221-1046
US

IV. Provider business mailing address

2099 NEW ALBANY RD
CINNAMINSON NJ
08077-3534
US

V. Phone/Fax

Practice location:
  • Phone: 609-926-8899
  • Fax: 609-926-6474
Mailing address:
  • Phone: 609-926-8899
  • Fax: 609-653-8713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MB06289800
License Number StateNJ

VIII. Authorized Official

Name: COYLE S CONNOLLY
Title or Position: PRESIDENT
Credential: DO
Phone: 609-926-8899