Healthcare Provider Details

I. General information

NPI: 1861770406
Provider Name (Legal Business Name): JOHN T REILLY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 BRANDER PARKWAY
SHELTER ISLAND NY
11964-1980
US

IV. Provider business mailing address

PO BOX 1980
SHELTER ISLAND NY
11964-1980
US

V. Phone/Fax

Practice location:
  • Phone: 631-831-2246
  • Fax: 631-749-1834
Mailing address:
  • Phone: 631-831-2246
  • Fax: 631-749-1834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014831
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: