Healthcare Provider Details

I. General information

NPI: 1942201629
Provider Name (Legal Business Name): JOHN P REILLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 11/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2444 W FAIDLEY AVE
GRAND ISLAND NE
68803-4327
US

IV. Provider business mailing address

PO BOX 550
GRAND ISLAND NE
68802-0550
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-1100
  • Fax: 308-385-0796
Mailing address:
  • Phone: 308-382-1100
  • Fax: 308-385-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number11469
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: