Provider Demographics
NPI:1720379019
Name:REILLEY, MATTHEW J (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:REILLEY
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-4000
Practice Address - Country:US
Practice Address - Phone:434-924-9333
Practice Address - Fax:434-243-6086
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101262474207RX0202X, 207RX0202X
PAMT198842207R00000X, 390200000X
TXBP10049000207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342841901Medicaid
TX382043YKQHMedicare PIN