Provider Demographics
NPI:1033123526
Name:REILLY, RICHARD L (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:REILLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-1370
Mailing Address - Country:US
Mailing Address - Phone:724-459-3411
Mailing Address - Fax:724-459-3412
Practice Address - Street 1:40 E MARKET ST
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-1370
Practice Address - Country:US
Practice Address - Phone:724-459-3411
Practice Address - Fax:724-459-3412
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003861213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015223780005Medicaid
PAU56362Medicare UPIN
PA776427Medicare ID - Type Unspecified