1750579967 NPI number — BEVERLY ANN REILLY ANP-C

Table of content: BEVERLY ANN REILLY ANP-C (NPI 1750579967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750579967 NPI number — BEVERLY ANN REILLY ANP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REILLY
Provider First Name:
BEVERLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750579967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 84068
Provider Second Line Business Mailing Address:
SENIOR HEALTH ASSOCIATES
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-757-1173
Provider Business Mailing Address Fax Number:
866-527-0937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 PLEASANT POINT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUFORT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29907-1164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-757-1173
Provider Business Practice Location Address Fax Number:
866-527-0937
Provider Enumeration Date:
10/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  4704231115 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 18184 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP2334 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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