MEDICARE: AMY G. CONNOLLY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601002695	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00191570	OTHER		RAILROAD MEDICARE

General Provider Information

NPI Number	:	1033106331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY G. CONNOLLY PA-C

Provider Business Mailing Address
First Line	:	7348 RAFFORD LN
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3190
Country	:	US
Telephone Number	:	248-592-0733
Fax Number	:

Provider Business Practice Location Address
First Line	:	22255 GREENFIELD RD STE 590
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-3734
Country	:	US
Telephone Number	:	248-849-4990
Fax Number	:	248-849-4991

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2005
Last Update Date	:	09/11/2024

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