Provider Demographics
NPI:1487629622
Name:ESTILL, MATTHEW REILLY (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:REILLY
Last Name:ESTILL
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1780 HANSHAW RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9105
Practice Address - Country:US
Practice Address - Phone:607-257-5858
Practice Address - Fax:607-257-1718
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202366-1207R00000X
PAMD058404L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015707040001Medicaid
NY01636502Medicaid
NYCC8362OtherRR MEDICARE GROUP
PAGU039812OtherMEDICARE GROUP
NY110209191OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
PA848237N8QMedicare ID - Type Unspecified
PA0015707040001Medicaid