Healthcare Provider Details

I. General information

NPI: 1649106006
Provider Name (Legal Business Name): PATRICK REILLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MIRACLE MILE DR
ROCHESTER NY
14623-5851
US

IV. Provider business mailing address

605 CROWS NEST LN
MACEDON NY
14502-8860
US

V. Phone/Fax

Practice location:
  • Phone: 585-704-3652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: