MEDICARE: DR. MICHAEL WALTER CONNELLY D.C.

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	111N00000X	Chiropractor	38MC00691700	NJ

General Provider Information

NPI Number	:	1790077576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL WALTER CONNELLY D.C.

Provider Business Mailing Address
First Line	:	24 HEMLOCK ST
Second Line	:
City	:	OAKLAND
State	:	NJ
Zip	:	07436-1829
Country	:	US
Telephone Number	:	201-403-4753
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 SADDLE RIVER AVE
Second Line	:
City	:	SOUTH HACKENSACK
State	:	NJ
Zip	:	07606-1952
Country	:	US
Telephone Number	:	201-880-4860
Fax Number	:

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

Provider Enumeration Date	:	05/11/2011
Last Update Date	:	05/11/2011

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