Healthcare Provider Details

I. General information

NPI: 1114996535
Provider Name (Legal Business Name): SCOTT J REILLY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 LONGWOOD AVE
BOSTON MA
02115-5711
US

IV. Provider business mailing address

11 SOUTH ST
WALPOLE MA
02081-3202
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-2314
  • Fax: 617-730-0320
Mailing address:
  • Phone: 508-668-6425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number215868
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: