Provider Demographics
NPI:1255350898
Name:REILLY, EDWARD J (PA)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:REILLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2473 STATE ROUTE 4
Mailing Address - Street 2:
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-3417
Mailing Address - Country:US
Mailing Address - Phone:770-375-9204
Mailing Address - Fax:
Practice Address - Street 1:1005 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-2607
Practice Address - Country:US
Practice Address - Phone:770-227-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05269-1363A00000X
GA004794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA939150895AMedicaid
GA939150895BMedicaid
GA202I972928Medicare PIN
GA939150895BMedicaid
202I972532Medicare PIN