Healthcare Provider Details

I. General information

NPI: 1629054796
Provider Name (Legal Business Name): JAMES J REILLY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203-2057
US

IV. Provider business mailing address

21 E 87TH ST APT. 9A
NEW YORK NY
10128-0506
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-4146
  • Fax:
Mailing address:
  • Phone: 212-426-3781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number192665
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: