Provider Demographics
NPI:1679592596
Name:REILLY, MARK F (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:F
Last Name:REILLY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 SUMMIT BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80021
Mailing Address - Country:US
Mailing Address - Phone:303-429-6448
Mailing Address - Fax:303-951-3701
Practice Address - Street 1:403 SUMMIT BLVD
Practice Address - Street 2:STE 201
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80021
Practice Address - Country:US
Practice Address - Phone:303-429-6448
Practice Address - Fax:303-429-6373
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7008225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC803962Medicare PIN
CO803962Medicare ID - Type UnspecifiedMEDICARE NUMBER