Healthcare Provider Details

I. General information

NPI: 1366735557
Provider Name (Legal Business Name): BRIAN CONNELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 W 1ST ST
DAYTON OH
45402-3095
US

IV. Provider business mailing address

3847 GARDENVIEW PL
KETTERING OH
45429-4516
US

V. Phone/Fax

Practice location:
  • Phone: 937-496-2620
  • Fax:
Mailing address:
  • Phone: 937-671-4315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: