Healthcare Provider Details

I. General information

NPI: 1114446317
Provider Name (Legal Business Name): CARMEN REID MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARMEN THUNEM

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W. OGDEN AVENUE
CHICAGO IL
60612-3227
US

IV. Provider business mailing address

1950 W POLK ST SUITE 5210
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-0200
  • Fax:
Mailing address:
  • Phone: 312-864-0394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.164409
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036.164409
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: