MEDICARE: PETER REILLY RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND5329	FL

General Provider Information

NPI Number	:	1679801666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER REILLY RD

Provider Business Mailing Address
First Line	:	7500 SW 59TH PL APT 110
Second Line	:
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-5133
Country	:	US
Telephone Number	:	718-349-3674
Fax Number	:

Provider Business Practice Location Address
First Line	:	7500 SW 59TH PL APT 110
Second Line	:
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-5133
Country	:	US
Telephone Number	:	718-349-3674
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2009
Last Update Date	:	12/02/2009

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Directions to “ PETER REILLY RD” Practice Location

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