Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0200X | Infectious Disease | 11049 | NE |
NPI | 1023031796 |
---|---|
Provider Name | Thomas L Connolly |
First Address | Omaha, NE 68124-2372 |
Second Address | Omaha, NE 68124-2372 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03553 | BLUE CROSS BLUE SHIELD NE (01) | NE |
D05069 | (02) | NE |