Provider Demographics
NPI:1821123977
Name:REILLY, BRIAN J (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 E OAKLAND AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5828
Mailing Address - Country:US
Mailing Address - Phone:309-663-5898
Mailing Address - Fax:
Practice Address - Street 1:2402 E OAKLAND AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5828
Practice Address - Country:US
Practice Address - Phone:309-663-5898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003992213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60001563OtherBLUE SHIELD PROVIDER #
IL213099Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
ILT38588Medicare UPIN
IL756410Medicare ID - Type UnspecifiedMEDICARE PROVIDER #