=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669581716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES REILLY MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1808 VERDUGO BLVD SUITE 209
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91208-1477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-949-4494
-----------------------------------------------------
Fax | 818-949-7330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1808 VERDUGO BLVD SUITE 209
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91208-1477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-949-4494
-----------------------------------------------------
Fax | 818-949-7330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JAMES FRANCIS REILLY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-949-4494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G51287
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------