Provider Demographics
NPI:1124061650
Name:CONNOLLY, KEVIN J (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 318
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033-0338
Mailing Address - Country:US
Mailing Address - Phone:802-222-5562
Mailing Address - Fax:802-222-9276
Practice Address - Street 1:437 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033-8877
Practice Address - Country:US
Practice Address - Phone:802-222-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT110105365OtherRAIL ROAD MEDICARE
VTOVN1126Medicaid
NHOX1895Medicare PIN
F16969Medicare UPIN
VTVN1126Medicare PIN
VTF16969Medicare PIN
VT110105365OtherRAIL ROAD MEDICARE