Provider Demographics
NPI:1124066915
Name:CONNELLY, PETER JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 BERWYN CT
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4671
Mailing Address - Country:US
Mailing Address - Phone:856-489-1990
Mailing Address - Fax:215-474-9983
Practice Address - Street 1:5942 HAVERFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151-4333
Practice Address - Country:US
Practice Address - Phone:215-474-9982
Practice Address - Fax:215-474-9983
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008818L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU84543Medicare UPIN