Provider Demographics
NPI:1689722878
Name:REILLY, THOMAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:M
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 1:8627 FOREST PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1143
Mailing Address - Country:US
Mailing Address - Phone:718-805-2404
Mailing Address - Fax:
Practice Address - Street 1:8627 FOREST PKWY
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-1143
Practice Address - Country:US
Practice Address - Phone:718-805-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144964207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE38245Medicare UPIN
NY59588Medicare ID - Type Unspecified