Provider Demographics
NPI:1053385443
Name:REILLY, DAVID M (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:REILLY
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 1:3655 KENT DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-3753
Mailing Address - Country:US
Mailing Address - Phone:606-875-1369
Mailing Address - Fax:
Practice Address - Street 1:350 HOSPITAL WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2872
Practice Address - Country:US
Practice Address - Phone:606-451-2601
Practice Address - Fax:606-451-2641
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31406207Q00000X
FLME134181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5635067OtherAETNA
C92456OtherCUMBERLAND HEALTHCARE
KY64314065Medicaid
000000226630OtherANTHEM
1165848OtherCHA
5225606OtherCCN
FL023209000Medicaid
KY080145046OtherRAILROAD MEDICARE
$$$$$$$$$-00OtherOHIO WORKERS COMP
0594416Medicare PIN