Healthcare Provider Details

I. General information

NPI: 1154385847
Provider Name (Legal Business Name): MARY KATHLEEN REILLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W 7TH AVE 410 & 420
SPOKANE WA
99204-2349
US

IV. Provider business mailing address

122 W 7TH AVE 410 & 420
SPOKANE WA
99204-2349
US

V. Phone/Fax

Practice location:
  • Phone: 509-838-8286
  • Fax: 509-625-1888
Mailing address:
  • Phone: 509-838-8286
  • Fax: 509-625-1888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD00031808
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: