1881718864 NPI number — KATHRYN MILLER REILLY PH.D.

Table of content: KATHRYN MILLER REILLY PH.D. (NPI 1881718864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881718864 NPI number — KATHRYN MILLER REILLY PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REILLY
Provider First Name:
KATHRYN
Provider Middle Name:
MILLER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881718864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44242 ARLINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48187-2144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-516-7424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19855 OUTER DR
Provider Second Line Business Practice Location Address:
103B-W
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48124-2022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-359-1977
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2007

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: 103TC0700X , with the licence number:  6301008955 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11283769 . This is a "CAQH ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 38-3304817 . This is a "TAX ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 680H247650 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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