Healthcare Provider Details

I. General information

NPI: 1114754793
Provider Name (Legal Business Name): JENNIFER RIEDEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE STE 1304
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125087939
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: