Provider Demographics
NPI:1679645758
Name:REILLY, PHILIP J JR (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:REILLY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PHILIP
Other - Middle Name:JEROME
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:237 SECOND STREET
Mailing Address - City:SMITHTON
Mailing Address - State:PA
Mailing Address - Zip Code:15479-0479
Mailing Address - Country:US
Mailing Address - Phone:724-872-7202
Mailing Address - Fax:724-872-0775
Practice Address - Street 1:237 SECOND STREET
Practice Address - Street 2:
Practice Address - City:SMITHTON
Practice Address - State:PA
Practice Address - Zip Code:15479-0479
Practice Address - Country:US
Practice Address - Phone:724-872-7202
Practice Address - Fax:724-872-0775
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028690L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0617646Medicaid
PA0617646Medicaid