MEDICARE: DR. BRANDON KEITH CONNERLY MD

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	207Q00000X	Family Medicine Physician	01058296A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000000322352	OTHER	IN	BC/BS #

General Provider Information

NPI Number	:	1558361899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRANDON KEITH CONNERLY MD

Provider Business Mailing Address
First Line	:	PO BOX 38
Second Line	:
City	:	CORYDON
State	:	IN
Zip	:	47112-0038
Country	:	US
Telephone Number	:	812-738-4251
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 E WHISKEY RUN RD NE
Second Line	:
City	:	NEW SALISBURY
State	:	IN
Zip	:	47161-9345
Country	:	US
Telephone Number	:	812-347-9977
Fax Number	:

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	07/18/2022

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