Basic Information
| Provider Information | |||||||||
| NPI: | 1962505453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 07/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | E46044 | CT | N | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0222X | 000590 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 400000590CT01 | 01 | BCBS MAP | OTHER | OV9806 | 01 | PHS | OTHER | 061470493 | 01 | FIRST CHOICE | OTHER | 061470493 | 01 | UNITED PAYORS | OTHER | 400000590CT01 | 01 | BC HEALTH PLAN | OTHER | 400000590CT01 | 01 | BCBS NATL | OTHER | 061470493 | 01 | CT HEALTH PIONEER | OTHER | 400000590CT01 | 01 | BCBS FED PPO | OTHER | 061470493 | 01 | CHAMPUS TRICARE | OTHER | 061470493 | 01 | COMMUNITY | OTHER | 400000590CT01 | 01 | BCBS CENT 90 | OTHER | 004184694 | 05 | CT | MEDICAID | 061470493 | 01 | PHCS | OTHER | 061470493 | 01 | ONE HEALTH PLANHEALTH CAR | OTHER | 061470493 | 01 | NE DIRECT | OTHER | 095000 | 01 | CONNECTICARE | OTHER | 400000590CT01 | 01 | BCBS PREFERRED | OTHER |