Provider Demographics
NPI:1205846516
Name:REILLY, WILLIAM R (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:R
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:P.O. BOX 78399
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-8399
Mailing Address - Country:US
Mailing Address - Phone:618-939-4200
Mailing Address - Fax:618-939-4256
Practice Address - Street 1:509 HAMACHER ST STE 204
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1592
Practice Address - Country:US
Practice Address - Phone:618-939-4200
Practice Address - Fax:618-939-4256
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065044207RI0011X
IL036065044207RI0011X
MOR2F41207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202480307Medicaid
MOA10456Medicare UPIN
MO990001262Medicare ID - Type Unspecified
IL775370Medicare ID - Type Unspecified