Provider Demographics
NPI:1780910695
Name:REILLY, ROBERT MATHEW (RN)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MATHEW
Last Name:REILLY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ALEXANDER DR
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-3701
Mailing Address - Country:US
Mailing Address - Phone:631-383-7910
Mailing Address - Fax:631-581-6958
Practice Address - Street 1:5 ALEXANDER DR
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-3701
Practice Address - Country:US
Practice Address - Phone:631-383-7910
Practice Address - Fax:631-581-6958
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY619449-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse