Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | G43696 | CA |
N | 207XX0004X | Foot and Ankle Orthopaedic Surgeon | G43696 | CA |
NPI | 1578595468 |
---|---|
Provider Name | Mark A Reiley |
First Address | Berkeley, CA 94705-2059 |
Second Address | Berkeley, CA 94705-2059 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G436960 | (05) | CA |
00G436960 | BLUE SHIELD (01) | CA |
A49433 | (02) | CA |
G43696 | BLUE CROSS (01) | CA |
G43696 | STATE LICENSE (01) | CA |