Basic Information
| Provider Information | |||||||||
| NPI: | 1225134117 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLIAM R REILLY INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. LOUIS CARDIOVASCULAR CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78399 | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631788399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189394200 | ||||||||
| FaxNumber: | 6189394256 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 N. NEW BALLAS RD | ||||||||
| Address2: | STE 170W | ||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631416835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189394200 | ||||||||
| FaxNumber: | 6189394256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 02/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | REILLY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6189394200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | R2F41 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 20248037 | 05 | MO | MEDICAID |