Provider Demographics
NPI:1144612623
Name:MICHAEL T REILLY MD PA
Entity Type:Organization
Organization Name:MICHAEL T REILLY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-821-1132
Mailing Address - Street 1:1201 5TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1400
Mailing Address - Country:US
Mailing Address - Phone:727-821-1132
Mailing Address - Fax:727-822-2977
Practice Address - Street 1:1201 5TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1400
Practice Address - Country:US
Practice Address - Phone:727-821-1132
Practice Address - Fax:727-822-2977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D65308Medicare UPIN