Provider Demographics
NPI:1043921950
Name:REILLY, BRENDAN LEO (CERTIFIED PEER SPEC)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:LEO
Last Name:REILLY
Suffix:
Gender:M
Credentials:CERTIFIED PEER SPEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WILSON ST.
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550
Mailing Address - Country:US
Mailing Address - Phone:845-401-1605
Mailing Address - Fax:
Practice Address - Street 1:21 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5628
Practice Address - Country:US
Practice Address - Phone:845-238-6806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-688175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty