Healthcare Provider Details

I. General information

NPI: 1932180387
Provider Name (Legal Business Name): WALTER SCOTT REID DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST SUITE 530
PEORIA IL
61602-1005
US

IV. Provider business mailing address

900 MAIN ST SUITE 530
PEORIA IL
61602-1005
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5975
  • Fax: 309-655-1678
Mailing address:
  • Phone: 309-672-5975
  • Fax: 309-655-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036095933
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036095933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: