Provider Demographics
NPI:1053310904
Name:REILLY, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66201-0716
Mailing Address - Country:US
Mailing Address - Phone:913-791-4357
Mailing Address - Fax:913-791-4435
Practice Address - Street 1:20333 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5350
Practice Address - Country:US
Practice Address - Phone:913-791-4357
Practice Address - Fax:913-791-4435
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0423611207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203029111Medicaid
17552018OtherBLUE CROSS BLUE SHIELD
KS100276860AMedicaid
KS100276860AMedicaid
MO203029111Medicaid