MEDICARE: CONNOLLY LLC

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1164829487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNOLLY LLC

Provider Business Mailing Address
First Line	:	555 E NORTH LN STE 6020
Second Line	:
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2249
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 E NORTH LN STE 6020
Second Line	:
City	:	CONSHOHOCKEN
State	:	PA
Zip	:	19428-2249
Country	:	US
Telephone Number	:	203-423-1360
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR - ELIGIBILITY
Name	:	MR. BAILEY HANSFORD
Credential	:
Telephone Number	:	203-423-1360

Provider Enumeration Date	:	12/02/2014
Last Update Date	:	12/02/2014

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Directions to “CONNOLLY LLC ” Practice Location

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