Provider Demographics
NPI:1699701961
Name:REILLY, MICHAEL T (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
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 1:5301 N. DIXIE HWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-3403
Mailing Address - Country:US
Mailing Address - Phone:954-771-3334
Mailing Address - Fax:954-771-1069
Practice Address - Street 1:5301 N. DIXIE HWY
Practice Address - Street 2:SUITE 203
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334-3403
Practice Address - Country:US
Practice Address - Phone:954-771-3334
Practice Address - Fax:954-771-1069
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 45905207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07954AMedicare ID - Type Unspecified
FLC75481Medicare UPIN