Provider Demographics
NPI:1770642688
Name:REILLY, KERRY B (PA-C)
Entity type:Individual
Prefix:MS
First Name:KERRY
Middle Name:B
Last Name:REILLY
Suffix:
Gender:F
Credentials:PA-C
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 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVENUE NORTH
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655
Practice Address - Country:US
Practice Address - Phone:508-334-3278
Practice Address - Fax:508-334-7284
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2083363A00000X
MI5601003110363A00000X
RIPA00392363A00000X
NY006856-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P03909Medicare UPIN
MA000065101Medicare PIN