Provider Demographics
NPI:1407825854
Name:REILLY, JOHN F JR (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:REILLY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1991 SPROUL RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3512
Mailing Address - Country:US
Mailing Address - Phone:484-421-1669
Mailing Address - Fax:610-886-0164
Practice Address - Street 1:1991 SPROUL RD
Practice Address - Street 2:SUITE 600
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3512
Practice Address - Country:US
Practice Address - Phone:484-421-1669
Practice Address - Fax:610-886-0164
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005078L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E22157Medicare UPIN
0000501714Medicare ID - Type Unspecified
PA001218243Medicaid
E22157Medicare UPIN
PA155579YGA7Medicare PIN