Provider Demographics
NPI:1902890361
Name:REILLY, MICHELE QUINTANA (DO)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:QUINTANA
Last Name:REILLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:QUINTANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:20955 PROFESSIONAL PLZ
Practice Address - Street 2:STE 200
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3405
Practice Address - Country:US
Practice Address - Phone:703-729-7652
Practice Address - Fax:703-729-8746
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037069208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
370016509OtherRR MEDICARE
VA6704549Medicaid
370016509OtherRR MEDICARE
VA370001126Medicare PIN
VAC06319Medicare PIN