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NPI Code Detail

MEDICARE: JACOB CONNELLY

MEDICARE: JACOB CONNELLY
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
1207X00000XOrthopaedic Surgery PhysicianME144380FL
2207XX0005XSports Medicine (Orthopaedic Surgery) PhysicianME144380FL

General Provider Information

NPI Number : 1598184517
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB CONNELLY
Provider Business Mailing Address
First Line : 1050 SE MONTEREY RD STE 400
Second Line :
City : STUART
State : FL
Zip : 34994-4512
Country : US
Telephone Number : 772-288-2400
Fax Number : 772-419-0143
Provider Business Practice Location Address
First Line : 9401 SW DISCOVERY WAY STE 201
Second Line :
City : PORT SAINT LUCIE
State : FL
Zip : 34987-2381
Country : US
Telephone Number : 772-288-2400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/08/2014
Last Update Date : 02/28/2024

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