Provider Demographics
NPI:1548297252
Name:REID, CHURPHENA (MD)
Entity type:Individual
Prefix:DR
First Name:CHURPHENA
Middle Name:
Last Name:REID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1907
Mailing Address - Country:US
Mailing Address - Phone:309-495-0282
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1907
Practice Address - Country:US
Practice Address - Phone:309-495-0282
Practice Address - Fax:309-495-0298
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089160208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7215166OtherBCBS
ILK22019Medicare ID - Type Unspecified
IL7215166OtherBCBS
IL036089160-3Medicare ID - Type Unspecified