Healthcare Provider Details

I. General information

NPI: 1366740284
Provider Name (Legal Business Name): LISA MICHELLE HENRY-REID M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W POLK ST ROOM 1111
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

1900 W POLK ST ROOM 1111
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-3585
  • Fax: 312-864-9721
Mailing address:
  • Phone: 312-864-3585
  • Fax: 312-864-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-073772
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036073772
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: