Provider Demographics
NPI:1942201629
Name:REILLY, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-0550
Mailing Address - Country:US
Mailing Address - Phone:308-382-1100
Mailing Address - Fax:308-385-0796
Practice Address - Street 1:2444 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4327
Practice Address - Country:US
Practice Address - Phone:308-382-1100
Practice Address - Fax:308-385-0796
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11469207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10037720OtherPALMETTO GBA
NE47017633012Medicaid
NE2902OtherMIDLANDS CHOICE
NE904OtherBCBS
NE47017633012Medicaid
NE10037720OtherPALMETTO GBA
NE2902OtherMIDLANDS CHOICE