Provider Demographics
NPI:1356378376
Name:REILLY, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 NORTHWEST HWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FOX RIVER GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60021-1925
Mailing Address - Country:US
Mailing Address - Phone:847-550-9930
Mailing Address - Fax:847-961-6520
Practice Address - Street 1:912 NORTHWEST HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:FOX RIVER GROVE
Practice Address - State:IL
Practice Address - Zip Code:60021-1925
Practice Address - Country:US
Practice Address - Phone:847-550-9930
Practice Address - Fax:847-961-6520
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100776Medicaid
IL04932191OtherBLUE CROSS BLUE SHIELD
IL205667Medicare ID - Type Unspecified
IL036100776Medicaid