Provider Demographics
NPI:1558577635
Name:REILLY, DREW S
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:S
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 1:29 MARY LN
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND FORESIDE
Mailing Address - State:ME
Mailing Address - Zip Code:04110-1442
Mailing Address - Country:US
Mailing Address - Phone:203-913-3715
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007198225100000X
CTPENDING367500000X
MERNA223048367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist