MEDICARE: DR. JEREMY MCCONNELL M.D.

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	ME83356	FL
2	207QB0002X	Obesity Medicine (Family Medicine) Physician	ME83356	FL
3	207QS1201X	Sleep Medicine (Family Medicine) Physician	ME83356	FL

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	1700871969	OTHER	FL	NPI

General Provider Information

NPI Number	:	1700871969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY MCCONNELL M.D.

Provider Business Mailing Address
First Line	:	5717 21ST AVE WEST
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34209
Country	:	US
Telephone Number	:	941-792-8383
Fax Number	:	941-792-8484

Provider Business Practice Location Address
First Line	:	5717 21ST AVE WEST
Second Line	:
City	:	BRADENTON
State	:	FL
Zip	:	34209
Country	:	US
Telephone Number	:	941-792-8383
Fax Number	:	941-792-8484

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

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	11/29/2021

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