Provider Demographics
NPI:1982654406
Name:KILLILEA, EDWARD MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MICHAEL
Last Name:KILLILEA
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 1:111 GRAND PL
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-1846
Mailing Address - Country:US
Mailing Address - Phone:201-998-2142
Mailing Address - Fax:201-997-7650
Practice Address - Street 1:111 GRAND PL
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-1846
Practice Address - Country:US
Practice Address - Phone:201-998-2142
Practice Address - Fax:201-997-7650
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 27589207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC56135Medicare UPIN
NJ459694Medicare ID - Type Unspecified