=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558535559
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY J CONNOLLY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2008
-----------------------------------------------------
Last Update Date | 07/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 FODEN ROAD, EAST SUITE 203
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106-2327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-874-1489
-----------------------------------------------------
Fax | 207-523-8590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 FODEN RD, WEST SUITE 203
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-828-0361
-----------------------------------------------------
Fax | 207-874-1483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD18621
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 232521
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------