Provider Demographics
NPI:1053402628
Name:REILLY, KEVIN D (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
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 1:600 E 233RD ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2604
Mailing Address - Country:US
Mailing Address - Phone:718-920-9649
Mailing Address - Fax:718-920-6812
Practice Address - Street 1:600 E 233RD ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2604
Practice Address - Country:US
Practice Address - Phone:718-920-9649
Practice Address - Fax:718-920-6812
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY110521207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1249701Medicaid
NYKR05884320Medicare ID - Type Unspecified
NYB16992Medicare UPIN