=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821123977
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN J REILLY D.P.M.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2402 E OAKLAND AVE SUITE 5
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-5828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-663-5898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2402 E OAKLAND AVE SUITE 5
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-5828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-663-5898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 016003992
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ER0200X
-----------------------------------------------------
Taxonomy Name | Radiology Podiatrist
-----------------------------------------------------
License Number | 016003992
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213ES0000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine Podiatrist
-----------------------------------------------------
License Number | 016003992
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | 016003992
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------