Provider Demographics
NPI:1649775933
Name:OLD FASHION MEDICINE, INC
Entity type:Organization
Organization Name:OLD FASHION MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-409-3348
Mailing Address - Street 1:16722 ANNANDALE RD
Mailing Address - Street 2:
Mailing Address - City:EMMITSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21727-8908
Mailing Address - Country:US
Mailing Address - Phone:240-888-5023
Mailing Address - Fax:
Practice Address - Street 1:95 GATEPOST LANE
Practice Address - Street 2:APARTMENT 1B
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701
Practice Address - Country:US
Practice Address - Phone:240-409-3348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054749207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2853027000Medicaid