Provider Demographics
NPI:1427077965
Name:REILLY, THOMAS JUDE (MA, ATC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JUDE
Last Name:REILLY
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E CONDRON ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY
Mailing Address - State:NE
Mailing Address - Zip Code:68064-3401
Mailing Address - Country:US
Mailing Address - Phone:402-359-4412
Mailing Address - Fax:
Practice Address - Street 1:640 E 22ND ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2672
Practice Address - Country:US
Practice Address - Phone:402-721-3337
Practice Address - Fax:402-721-3338
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0718080Medicaid
NE100252598-00Medicaid
NE100252598-00Medicaid