Healthcare Provider Details

I. General information

NPI: 1326303678
Provider Name (Legal Business Name): KERRY K REILLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S MANNING BLVD RM 1677
ALBANY NY
12208-1789
US

IV. Provider business mailing address

315 S MANNING BLVD RM 1677
ALBANY NY
12208-1789
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-1550
  • Fax: 518-525-1722
Mailing address:
  • Phone: 518-525-1550
  • Fax: 518-525-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number015825
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: