Provider Demographics
NPI:1215987227
Name:CONNORS, MARILYN J (DO)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:J
Last Name:CONNORS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-4000
Mailing Address - Fax:
Practice Address - Street 1:609 N CAROL MALONE BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:KY
Practice Address - Zip Code:41143-1123
Practice Address - Country:US
Practice Address - Phone:606-474-7892
Practice Address - Fax:606-474-0040
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231855207Q00000X
SC1103207Q00000X
KY03296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3085101Medicaid
WV3810018418Medicaid
KYP00873783OtherRR MEDICARE
KY7100129340Medicaid
SC011036Medicaid
NY02550365Medicaid
KYP400024758Medicare PIN
SCF33146Medicare UPIN
SCAA21117603Medicare PIN
KY7100129340Medicaid
NY02550365Medicaid