Provider Demographics
NPI:1497849277
Name:REILLY, MARY (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 W OAK ST STE 130
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-2058
Mailing Address - Country:US
Mailing Address - Phone:765-571-3094
Mailing Address - Fax:317-795-1146
Practice Address - Street 1:1505 W OAK ST
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-2057
Practice Address - Country:US
Practice Address - Phone:844-539-8726
Practice Address - Fax:844-539-8726
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049057207P00000X, 207RH0002X
ININ01049057A2083B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200326470Medicaid
IN037870JJMedicare PIN