Provider Demographics
NPI:1518006865
Name:REILLY, GEORGE DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:DANIEL
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 1:31 Q MOUNTAIN BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5648
Mailing Address - Country:US
Mailing Address - Phone:908-753-7773
Mailing Address - Fax:908-753-8883
Practice Address - Street 1:31 Q MOUNTAIN BOULEVARD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5648
Practice Address - Country:US
Practice Address - Phone:908-753-7773
Practice Address - Fax:908-753-8883
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03575500207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1699601Medicaid
NJ452862Medicare ID - Type Unspecified