Healthcare Provider Details

I. General information

NPI: 1922091123
Provider Name (Legal Business Name): THOMAS CARROLL CONNOLLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/07/2023
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 THOMPSON ST
JERSEY SHORE PA
17740-1729
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-398-1991
  • Fax: 570-398-4607
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD035105E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: