Individual
JASON ROBERT CONNELLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
335 SCHOOL ST, CLEVELAND, NC 27013-9501
(704) 210-7885
(704) 210-7898
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
200000386
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
126RG
BLUE CROSS BLUE SHIELD NC
NC
05
—
89126RG
—
NC
Enumeration date
08/02/2005
Last updated
10/28/2020
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