Healthcare Provider Details

I. General information

NPI: 1508685595
Provider Name (Legal Business Name): REILLY COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR STE 117
CHICAGO IL
60611-4448
US

IV. Provider business mailing address

411 W FULLERTON PKWY APT 1505W
CHICAGO IL
60614-2838
US

V. Phone/Fax

Practice location:
  • Phone: 312-288-6420
  • Fax:
Mailing address:
  • Phone: 847-507-8848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: