Basic Information
| Provider Information | |||||||||
| NPI: | 1881640134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1559 | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117900989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317028327 | ||||||||
| FaxNumber: | 6317028314 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 COUNTY ROAD 39A | ||||||||
| Address2: | |||||||||
| City: | SOUTHAMPTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119685241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314440058 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 09/27/2018 | ||||||||
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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 | 207RC0000X | MD.14569R | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD.14569R | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 198597 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 00126429 | 05 | MS | MEDICAID | 1131938 | 05 | LA | MEDICAID |