MEDICARE: KATHERINE MARIE CONNELLY 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	207P00000X	Emergency Medicine Physician	35.142306	OH
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207P00000X	Emergency Medicine Physician	81557-20	WI

General Provider Information

NPI Number	:	1912402140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE MARIE CONNELLY MD

Provider Business Mailing Address
First Line	:	3703 GROVEDALE PL APT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-1108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3703 GROVEDALE PL APT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-1108
Country	:	US
Telephone Number	:	720-840-0147
Fax Number	:

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

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	08/20/2024

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