Provider Demographics
NPI:1699799981
Name:REILLY, MARK W (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:REILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24 S 1100 E
Mailing Address - Street 2:SUITE #306
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1500
Mailing Address - Country:US
Mailing Address - Phone:801-359-8956
Mailing Address - Fax:801-355-5250
Practice Address - Street 1:1050 E SOUTH TEMPLE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1507
Practice Address - Country:US
Practice Address - Phone:801-350-8400
Practice Address - Fax:801-350-4021
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12470A2085R0001X
UT187816-12052085R0001X
MT109602085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000092076OtherBLUE CROSS BLUE SHIELD MT
MT1699799981Medicaid
UT000064427Medicare PIN
MT000092076OtherBLUE CROSS BLUE SHIELD MT
MT000085087Medicare PIN