MEDICARE: MICHAEL C CONNELLY 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	208VP0014X	Interventional Pain Medicine Physician	58770	MA
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	58770	MA
3	207LP2900X	Pain Medicine (Anesthesiology) Physician	12648	NH

General Provider Information

NPI Number	:	1710987615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL C CONNELLY M.D.

Provider Business Mailing Address
First Line	:	354 MERRIMACK STREET
Second Line	:	BLDG. 1
City	:	LAWRENCE
State	:	MA
Zip	:	01843
Country	:	US
Telephone Number	:	978-687-2321
Fax Number	:	978-722-7287

Provider Business Practice Location Address
First Line	:	354 MERRIMACK ST STE 1
Second Line	:
City	:	LAWRENCE
State	:	MA
Zip	:	01843-1755
Country	:	US
Telephone Number	:	978-687-2321
Fax Number	:	978-722-7287

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	03/04/2020

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