Provider Demographics
NPI:1194930016
Name:RICHARD L REILLY DPM
Entity type:Organization
Organization Name:RICHARD L REILLY DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:724-459-3411
Mailing Address - Street 1:40 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-1370
Mailing Address - Country:US
Mailing Address - Phone:724-459-3411
Mailing Address - Fax:724-459-3412
Practice Address - Street 1:40 E MARKET ST
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-1370
Practice Address - Country:US
Practice Address - Phone:724-459-3411
Practice Address - Fax:724-459-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003861174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015223780005Medicaid
PA761516OtherBCBS
PA761516OtherBCBS
PA0015223780005Medicaid