Provider Demographics
NPI:1427189323
Name:REILLY, KEVIN PATRICK (DC,CCSP)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PATRICK
Last Name:REILLY
Suffix:
Gender:M
Credentials:DC,CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2507
Mailing Address - Country:US
Mailing Address - Phone:614-488-8182
Mailing Address - Fax:614-488-9707
Practice Address - Street 1:1245 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2507
Practice Address - Country:US
Practice Address - Phone:614-488-8182
Practice Address - Fax:614-488-9707
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1809111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311360784OtherTAX ID NUMBER
OHU39660Medicare UPIN
OHRE0733121Medicare ID - Type Unspecified