Provider Demographics
NPI:1568830453
Name:REILLY, GARRETT
Entity Type:Individual
Prefix:
First Name:GARRETT
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 1:202 CURTISS DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-6120
Mailing Address - Country:US
Mailing Address - Phone:850-586-0042
Mailing Address - Fax:
Practice Address - Street 1:202 CURTISS DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-6120
Practice Address - Country:US
Practice Address - Phone:850-586-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program