Provider Demographics
NPI:1487604369
Name:CONNOLLY, SUZANNE D (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:D
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 COLUMBIA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-1487
Mailing Address - Country:US
Mailing Address - Phone:440-808-1925
Mailing Address - Fax:440-808-1926
Practice Address - Street 1:805 COLUMBIA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1487
Practice Address - Country:US
Practice Address - Phone:440-808-1925
Practice Address - Fax:440-808-1926
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35086814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2616664Medicaid
I48762Medicare UPIN
OH7340171Medicare PIN
OH4258551Medicare PIN