Provider Demographics
NPI:1538342373
Name:REILLY, KEVIN D
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:D
Last Name:REILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 BROADMOOR TRL
Mailing Address - Street 2:PO BOX 231
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9386
Mailing Address - Country:US
Mailing Address - Phone:585-388-0931
Mailing Address - Fax:585-425-2327
Practice Address - Street 1:1792 N GOODMAN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-1036
Practice Address - Country:US
Practice Address - Phone:585-467-4422
Practice Address - Fax:585-266-3057
Is Sole Proprietor?:No
Enumeration Date:2007-12-16
Last Update Date:2007-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00446846Medicaid