Healthcare Provider Details

I. General information

NPI: 1497825863
Provider Name (Legal Business Name): ERIC VINCENT REINERTSON M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 BROADWAY ST
PEKIN IL
61554-3905
US

IV. Provider business mailing address

2401 BROADWAY ST
PEKIN IL
61554-3905
US

V. Phone/Fax

Practice location:
  • Phone: 309-478-1700
  • Fax: 309-478-1701
Mailing address:
  • Phone: 309-478-1700
  • Fax: 309-478-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-097075
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: