Provider Demographics
NPI:1053367516
Name:COYLE S CONNOLLY DO PA
Entity type:Organization
Organization Name:COYLE S CONNOLLY DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COYLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-926-8899
Mailing Address - Street 1:2099 NEW ALBANY RD
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-3534
Mailing Address - Country:US
Mailing Address - Phone:609-926-8899
Mailing Address - Fax:609-653-8713
Practice Address - Street 1:2106 NEW RD
Practice Address - Street 2:SUITE D4
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1046
Practice Address - Country:US
Practice Address - Phone:609-926-8899
Practice Address - Fax:609-926-6474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06289800207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDE5501OtherMEDICARE RAILROAD
NJ052076Medicare PIN