Provider Demographics
NPI:1760475586
Name:REILLY, JEFFREY M (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:REILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 STONEFOREST DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4881
Mailing Address - Country:US
Mailing Address - Phone:770-423-0595
Mailing Address - Fax:678-388-1627
Practice Address - Street 1:61 WHITCHER STREET NE
Practice Address - Street 2:SUITE 2100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-423-0595
Practice Address - Fax:770-874-1614
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0470182086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000818925AMedicaid
GA000818925AMedicaid
GA77BBBGRMedicare ID - Type Unspecified