Healthcare Provider Details

I. General information

NPI: 1669289005
Provider Name (Legal Business Name): EMILY REINWALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2073 N CLYBOURN AVE
CHICAGO IL
60614-4003
US

IV. Provider business mailing address

1278 BERKSHIRE LN
GRAYSLAKE IL
60030-4206
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-4016
  • Fax: 773-360-6200
Mailing address:
  • Phone: 847-849-0327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010896
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: