Basic Information
| Provider Information | |||||||||
| NPI: | 1326092370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNALLY | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | SHI | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053076668 | ||||||||
| FaxNumber: | 4053076660 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 EAST ROBINSON | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053294102 | ||||||||
| FaxNumber: | 4053075627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 23363 | OK | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200014890B | 05 | OK | MEDICAID | P00072417 | 01 | OK | MEDICARE RAILROAD | OTHER | 200014890A | 05 | OK | MEDICAID |