Healthcare Provider Details

I. General information

NPI: 1124061650
Provider Name (Legal Business Name): KEVIN J. CONNOLLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 S MAIN ST
BRADFORD VT
05033-8877
US

IV. Provider business mailing address

P O BOX 318
BRADFORD VT
05033-0338
US

V. Phone/Fax

Practice location:
  • Phone: 802-222-5562
  • Fax:
Mailing address:
  • Phone: 802-222-5562
  • Fax: 802-222-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0420009101
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: