Provider Demographics
NPI:1174533160
Name:CONNERLY, PATRICK W (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:W
Last Name:CONNERLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:1515 HOBSON RD.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6601
Practice Address - Fax:260-969-3067
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-04-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01024447A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100081390BMedicaid
INM400023951Medicare PIN
INM400036233Medicare PIN
INB29333Medicare UPIN
IN100081390BMedicaid
IN080130671Medicare PIN
IN070860VVVVMedicare PIN
INM400036230Medicare PIN