Provider Demographics
NPI:1275529661
Name:REILLY, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 STATE ST FL 4
Mailing Address - Street 2:4TH FLOOR, SUITE 401
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 STATE ST FL 4
Practice Address - Street 2:4TH FLOOR, SUITE 401
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1427
Practice Address - Country:US
Practice Address - Phone:814-877-8680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021584E208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000642783Medicaid
PA0006427830001Medicaid
PARE092939Medicare ID - Type Unspecified
C29641Medicare UPIN
PA000642783Medicaid