Provider Demographics
NPI:1033122098
Name:REILLY, PETER J (NP)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BALD HILL RD
Mailing Address - Street 2:SUITE 526
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1617
Mailing Address - Country:US
Mailing Address - Phone:401-738-4323
Mailing Address - Fax:401-738-3857
Practice Address - Street 1:400 BALD HILL RD
Practice Address - Street 2:SUITE 526
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-1617
Practice Address - Country:US
Practice Address - Phone:401-738-4323
Practice Address - Fax:401-738-3857
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP35094363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9025374Medicaid
RIS58272Medicare UPIN