Basic Information
| Provider Information | |||||||||
| NPI: | 1689614133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REILLY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 301 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862316000 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862316000 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 9400615 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | ME143257 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 8971181 | 05 | NC | MEDICAID | 5290539 | 01 | SC | CIGNA | OTHER | 1220039 | 01 | SC | UNITED | OTHER | 5074302 | 01 | SC | AETNA | OTHER | Q0061W | 05 | SC | MEDICAID | 30246444 | 01 | SC | SELECT HEALTH MEDICAID LINE | OTHER | 80067958 | 01 | SC | SELECT HEALTH | OTHER | 1205888 | 01 | FL | WELLCARE | OTHER | P01604823 | 01 | SC | RR MEDICARE | OTHER |