Healthcare Provider Details

I. General information

NPI: 1215314257
Provider Name (Legal Business Name): KEVIN PATRICK CONNOLLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LANCASTER DR NE
SALEM OR
97305-1221
US

IV. Provider business mailing address

500 NE MULTNOMAH ST STE 100
PORTLAND OR
97232-2031
US

V. Phone/Fax

Practice location:
  • Phone: 800-813-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD192844
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA153322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: