Provider Demographics
NPI:1427067685
Name:REILLY, KEVIN DONALD (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DONALD
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 1:2345 MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2861
Mailing Address - Country:US
Mailing Address - Phone:541-285-1434
Mailing Address - Fax:888-972-6544
Practice Address - Street 1:999 WILLAMETTE ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3112
Practice Address - Country:US
Practice Address - Phone:541-687-9314
Practice Address - Fax:888-972-6544
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028312Medicaid
ORQ04624Medicare UPIN
OR117362Medicare ID - Type UnspecifiedMEDICARE MEMBER