Basic Information
| Provider Information | |||||||||
| NPI: | 1750369419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNOLLY | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 03/18/2011 | ||||||||
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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 | 207X00000X | 036093095 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 28464 | IA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036093095 | 05 | IL | MEDICAID | 200029113 | 01 | RR MEDICARE | OTHER | 1917237 | 05 | IA | MEDICAID | 8121085 | 01 | IL | BCBS | OTHER | IA0194 | 01 | JOHN DEERE FAMILY | OTHER | 18604 | 01 | MIDLANDS CHOICE | OTHER | 05353 | 01 | WELLMARK | OTHER | 20170 | 01 | IA HEALTH SOLUTIONS | OTHER | 028389 | 01 | HEALTH ALLIANCE | OTHER | 99717 | 01 | WELLMARK | OTHER | 99728 | 01 | WELLMARK | OTHER | IL0174 | 01 | JOHN DEERE FAMILY | OTHER |