Provider Demographics
NPI:1215092416
Name:REILLY, THOMAS A (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
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:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71116-1768
Mailing Address - Country:US
Mailing Address - Phone:318-677-7450
Mailing Address - Fax:318-425-5815
Practice Address - Street 1:850 MARGARET PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4521
Practice Address - Country:US
Practice Address - Phone:318-222-8187
Practice Address - Fax:318-424-2637
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05352R207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1324329Medicaid
B65526Medicare UPIN
54934Medicare ID - Type Unspecified