Provider Demographics
NPI:1730149105
Name:CONNOLLY, MARY JO
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 570
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3723
Mailing Address - Country:US
Mailing Address - Phone:651-232-4800
Mailing Address - Fax:651-232-4899
Practice Address - Street 1:1690 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 570
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3723
Practice Address - Country:US
Practice Address - Phone:651-232-4800
Practice Address - Fax:651-232-4899
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24765207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNB58327Medicare UPIN