Provider Demographics
NPI:1174892582
Name:REILLY, JOAN (APN)
Entity type:Individual
Prefix:MISS
First Name:JOAN
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S MARYLAND AVE
Mailing Address - Street 2:PEDIATRICS
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1447
Mailing Address - Country:US
Mailing Address - Phone:773-834-8850
Mailing Address - Fax:773-834-5365
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:PEDIATRICS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-834-8850
Practice Address - Fax:773-834-5365
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.001549208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics