Basic Information
| Provider Information | |||||||||
| NPI: | 1730146069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7866 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514765443 | ||||||||
| FaxNumber: | 2514760116 | ||||||||
| Practice Location | |||||||||
| Address1: | 1613 N MCKENZIE ST | ||||||||
| Address2: | |||||||||
| City: | FOLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365352247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514765443 | ||||||||
| FaxNumber: | 2514760116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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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 | 2085R0202X | 24737 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 009936421 | 05 | AL | MEDICAID | 51003532 | 01 | AL | BC MONTCLAIR | OTHER | 009936423 | 05 | AL | MEDICAID | 51003530 | 01 | AL | BC GREYSTONE | OTHER | 51003540 | 01 | AL | BC SYLACAUGA | OTHER | 51003538 | 01 | AL | BC SHELBY | OTHER | 009936422 | 05 | AL | MEDICAID | 009936426 | 05 | AL | MEDICAID | 009936424 | 05 | AL | MEDICAID | 51003539 | 01 | AL | BC 280 | OTHER |