Provider Demographics
NPI:1487611232
Name:REAVY, DAVID A (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:REAVY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 N DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2522
Mailing Address - Country:US
Mailing Address - Phone:312-380-1822
Mailing Address - Fax:312-313-8995
Practice Address - Street 1:1520 N DAYTON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2522
Practice Address - Country:US
Practice Address - Phone:312-380-1822
Practice Address - Fax:312-313-8995
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011211225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILK08154Medicare ID - Type Unspecified
ILP00368309Medicare UPIN
ILP00368309Medicare PIN
P94677Medicare UPIN