Provider Demographics
NPI:1912569286
Name:REILLY, PATRICK P
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:P
Last Name:REILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 FANNING AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946
Mailing Address - Country:US
Mailing Address - Phone:631-603-5996
Mailing Address - Fax:
Practice Address - Street 1:51 FANNING AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946
Practice Address - Country:US
Practice Address - Phone:631-603-5996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010044225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010044Medicaid