Healthcare Provider Details

I. General information

NPI: 1891717229
Provider Name (Legal Business Name): ANDREW J CONNOLLY PT, OCS, FAAOMPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 MAIN ST STE 120
UNION GROVE WI
53182-1074
US

IV. Provider business mailing address

24014 W RENWICK RD UNIT 206
PLAINFIELD IL
60544-8711
US

V. Phone/Fax

Practice location:
  • Phone: 800-974-4378
  • Fax: 630-515-1536
Mailing address:
  • Phone: 800-974-4378
  • Fax: 630-515-1536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5392-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: