Healthcare Provider Details

I. General information

NPI: 1205233418
Provider Name (Legal Business Name): MARY T REILLY PELINI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY THERESE REILLY PA-C

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PERKINS SQ
AKRON OH
44308-1063
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-8580
  • Fax: 330-543-3220
Mailing address:
  • Phone: 330-543-8580
  • Fax: 330-543-3220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.004173
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004173RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: