Provider Demographics
NPI:1558580357
Name:THOMAS A REILLY MD APMC
Entity Type:Organization
Organization Name:THOMAS A REILLY MD APMC
Other - Org Name:SHREVEPORT GERIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-222-8187
Mailing Address - Street 1:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71116-1768
Mailing Address - Country:US
Mailing Address - Phone:318-677-7450
Mailing Address - Fax:318-425-5815
Practice Address - Street 1:850 MARGARET PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4521
Practice Address - Country:US
Practice Address - Phone:318-222-8187
Practice Address - Fax:318-424-2637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1948799Medicaid
5C376Medicare ID - Type Unspecified