Basic Information
Provider Information | |||||||||
NPI: | 1992725089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REILLY | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 LAKE SUMTER LNDG | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321622699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526748820 | ||||||||
FaxNumber: | 3526748919 | ||||||||
Practice Location | |||||||||
Address1: | 280 FARNER PLACE | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 32163 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526741710 | ||||||||
FaxNumber: | 3526748910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2006 | ||||||||
LastUpdateDate: | 04/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 235350 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | ME116741 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 02710938 | 05 | NY |   | MEDICAID | 7347764 | 01 | NY | AETNA | OTHER | ME116741 | 01 | FL | FLORIDA MEDICAL LICENSE | OTHER | 179SZ2 | 01 | NY | EMPIRE BC.BS | OTHER |