Healthcare Provider Details

I. General information

NPI: 1841410743
Provider Name (Legal Business Name): MICHAEL D CONNOLLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST STE 470
PROVIDENCE RI
02905-3248
US

IV. Provider business mailing address

15 LASALLE SQUARE
PROVIDENCE RI
02903
US

V. Phone/Fax

Practice location:
  • Phone: 401-553-8355
  • Fax: 401-868-2328
Mailing address:
  • Phone: 401-444-3239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD12986
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: