Healthcare Provider Details

I. General information

NPI: 1285210773
Provider Name (Legal Business Name): JACOB PADRAIG REILLEY LUTHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21481 N RAND RD FL 2
KILDEER IL
60047-3061
US

IV. Provider business mailing address

275 HOSPITAL PKWY STE 700
SAN JOSE CA
95119-1102
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7845
  • Fax: 847-618-0676
Mailing address:
  • Phone: 408-972-3807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036170914
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA184683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: