Basic Information
| Provider Information | |||||||||
| NPI: | 1053385443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY STE 301 | ||||||||
| Address2: | |||||||||
| City: | NORTH FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 TAMIAMI TRL STE A | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339523922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416242704 | ||||||||
| FaxNumber: | 9416276066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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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 | 207Q00000X | ME134181 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 31406 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1165848 | 01 | CHA | OTHER | 5225606 | 01 | CCN | OTHER | 5635067 | 01 | AETNA | OTHER | C92456 | 01 | CUMBERLAND HEALTHCARE | OTHER | 023209000 | 05 | FL | MEDICAID | 64314065 | 05 | KY | MEDICAID | 000000226630 | 01 | ANTHEM | OTHER | 080145046 | 01 | KY | RAILROAD MEDICARE | OTHER |