Basic Information
| Provider Information | |||||||||
| NPI: | 1659307296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELL | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 HIGHWAY 61 N | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391838211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018835000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 HIGHWAY 61 N | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391838211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018835000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 16732 | MS | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 7023123 | 01 | MS | AETNA | OTHER | 0122875 | 05 | MS | MEDICAID | 1483621 | 05 | LA | MEDICAID |