Healthcare Provider Details

I. General information

NPI: 1982606497
Provider Name (Legal Business Name): RICHARD MAST REINHARD III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 N CLYBOURN AVE
CHICAGO IL
60610-2089
US

IV. Provider business mailing address

1276 N CLYBOURN AVE
CHICAGO IL
60610-2003
US

V. Phone/Fax

Practice location:
  • Phone: 312-337-1073
  • Fax: 312-337-7616
Mailing address:
  • Phone: 312-337-1073
  • Fax: 312-337-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-2211
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58522
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.168144
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: