Healthcare Provider Details

I. General information

NPI: 1174892582
Provider Name (Legal Business Name): JOAN REILLY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE PEDIATRICS
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

5841 S MARYLAND AVE PEDIATRICS
CHICAGO IL
60637-1447
US

V. Phone/Fax

Practice location:
  • Phone: 773-834-8850
  • Fax: 773-834-5365
Mailing address:
  • Phone: 773-834-8850
  • Fax: 773-834-5365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number209.001549
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: