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NPI Code Detail

MEDICARE: DR. CHARLES WILLIAM CONNOLLY DPM

MEDICARE: DR. CHARLES WILLIAM CONNOLLY DPM
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
1213E00000XPodiatrist1784MA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1Y70860OTHERMABLUE SHIELD OF MA
2709158OTHERMATUFTS HEALTH PLAN
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
433386OTHERMAHARVARD PILGRIM HEALTH CA
52700037OTHERMAUNITED HEALTHCARE

General Provider Information

NPI Number : 1932105095
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CHARLES WILLIAM CONNOLLY DPM
Provider Business Mailing Address
First Line : 120 COLLEGE AVE
Second Line :
City : SOMERVILLE
State : MA
Zip : 02144-1919
Country : US
Telephone Number : 781-593-1700
Fax Number :
Provider Business Practice Location Address
First Line : 120 COLLEGE AVE
Second Line :
City : SOMERVILLE
State : MA
Zip : 02144-1919
Country : US
Telephone Number : 617-776-2500
Fax Number : 617-776-3850
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2005
Last Update Date : 04/24/2012

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