Provider Demographics
NPI:1205255353
Name:REILY, ROBERT EMMETT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EMMETT
Last Name:REILY
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 1:7777 HENNESSY BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4363
Mailing Address - Country:US
Mailing Address - Phone:225-765-2048
Mailing Address - Fax:225-765-1958
Practice Address - Street 1:1017 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5240
Practice Address - Country:US
Practice Address - Phone:404-401-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA3221432086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program