Provider Demographics
NPI:1215987508
Name:CONNOLLY, JOHN E (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
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 1:2233 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8151
Mailing Address - Country:US
Mailing Address - Phone:312-770-3990
Mailing Address - Fax:312-770-2161
Practice Address - Street 1:2233 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-8151
Practice Address - Country:US
Practice Address - Phone:312-770-3990
Practice Address - Fax:312-770-2161
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360918232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091823Medicaid
ILG58586Medicare UPIN
ILK27321Medicare PIN