Provider Demographics
NPI:1700828472
Name:REILLY, THERESA KORNELUK (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:KORNELUK
Last Name:REILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4403
Mailing Address - Country:US
Mailing Address - Phone:215-634-6660
Mailing Address - Fax:215-739-6777
Practice Address - Street 1:2418 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4403
Practice Address - Country:US
Practice Address - Phone:215-634-6660
Practice Address - Fax:215-739-6777
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA020803E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0842013Medicaid
PAE80598Medicare UPIN