Provider Demographics
NPI:1265475115
Name:REILLY, THOMAS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
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 1:330 CORDOVA ST
Mailing Address - Street 2:APT #155
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2451
Mailing Address - Country:US
Mailing Address - Phone:626-786-7578
Mailing Address - Fax:
Practice Address - Street 1:4929 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1702
Practice Address - Country:US
Practice Address - Phone:818-907-4570
Practice Address - Fax:818-907-2814
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48776207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A487760Medicaid
CA00A487760Medicaid
CAWA48776Medicare PIN
CAF10635Medicare UPIN