Provider Demographics
NPI:1174511802
Name:CONNELLY, GEORGE MARTIN (PA-C, MHP)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:MARTIN
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:PA-C, MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-1185
Mailing Address - Country:US
Mailing Address - Phone:802-388-3194
Mailing Address - Fax:802-388-4881
Practice Address - Street 1:1436 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1185
Practice Address - Country:US
Practice Address - Phone:802-388-3194
Practice Address - Fax:802-388-4881
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030564207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2001415Medicaid
VTR17681Medicare UPIN
VTCOAP1576Medicare ID - Type Unspecified