Healthcare Provider Details

I. General information

NPI: 1750574299
Provider Name (Legal Business Name): THOMAS BRADLEY REILLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2007
Last Update Date: 11/12/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11603 SHELDON RD RESTORE BRAIN SPORT AND SPINE
TAMPA FL
33626-4306
US

IV. Provider business mailing address

11603 SHELDON RD
TAMPA FL
33626-4306
US

V. Phone/Fax

Practice location:
  • Phone: 516-680-8080
  • Fax:
Mailing address:
  • Phone: 727-935-4142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME124236
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME124236
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME124236
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: