Provider Demographics
NPI:1669414694
Name:REILLY, JOSEPH C (PT)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:C
Last Name:REILLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 TAMIAMI TRL S
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5001
Mailing Address - Country:US
Mailing Address - Phone:941-408-8800
Mailing Address - Fax:941-408-0255
Practice Address - Street 1:4119 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-5109
Practice Address - Country:US
Practice Address - Phone:941-408-8800
Practice Address - Fax:941-408-0255
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT14970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8941OtherBCBS OF FL
FL650019630OtherRAIL ROAD MEDICARE
FLY8941OtherBCBS OF FL