Provider Demographics
NPI:1154398519
Name:CONNOLLY, KATHLEEN V (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:V
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 PARK STREET
Mailing Address - Street 2:STURDY MEMORIAL HOSPITAL
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703
Mailing Address - Country:US
Mailing Address - Phone:508-236-7810
Mailing Address - Fax:
Practice Address - Street 1:211 PARK STREET
Practice Address - Street 2:STURDY MEMORIAL HOSPITAL
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703
Practice Address - Country:US
Practice Address - Phone:508-236-7810
Practice Address - Fax:508-236-7806
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73764207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3110117Medicaid
MA3110117Medicaid
F64506Medicare UPIN