Provider Demographics
NPI:1871586420
Name:REILLY, EILEEN B (MD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:B
Last Name:REILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 UNION RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-1465
Mailing Address - Country:US
Mailing Address - Phone:716-651-0911
Mailing Address - Fax:716-651-9855
Practice Address - Street 1:6400 POWERS RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-4841
Practice Address - Country:US
Practice Address - Phone:716-667-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0492309OtherINDEPENDENT HEALTH
NY02212779Medicaid
NY000925074002OtherBC/BS
NY0492309OtherINDEPENDENT HEALTH
NYRA4479Medicare ID - Type Unspecified
NY000925074002OtherBC/BS
NYP00684221Medicare PIN