Basic Information
Provider Information | |||||||||
NPI: | 1093791444 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONNAUGHTON | ||||||||
FirstName: | JOANNE | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STOREY | ||||||||
OtherFirstName: | JOANNE | ||||||||
OtherMiddleName: | T | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 5525 RESEARCH PARK DR FL 4 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212284873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6103874520 | ||||||||
FaxNumber: | 6103874526 | ||||||||
Practice Location | |||||||||
Address1: | 1553 CHESTER PIKE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | CRUM LYNNE | ||||||||
State: | PA | ||||||||
PostalCode: | 190221022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104997180 | ||||||||
FaxNumber: | 6108760859 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2005 | ||||||||
LastUpdateDate: | 10/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD043655E | PA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0011846190005 | 05 | PA |   | MEDICAID |