Healthcare Provider Details

I. General information

NPI: 1275529661
Provider Name (Legal Business Name): JOHN REILLY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 03/25/2021
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 STATE ST FL 4 4TH FLOOR, SUITE 401
ERIE PA
16507-1427
US

IV. Provider business mailing address

300 STATE ST FL 4 4TH FLOOR, SUITE 401
ERIE PA
16507-1427
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-8680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD021584E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: