Provider Demographics
NPI:1023006392
Name:REID, JERI ROBERTA (MD)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:ROBERTA
Last Name:REID
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JERI
Other - Middle Name:ROBERTA
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1930 BISHOP LN
Practice Address - Street 2:SUITE 1600
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1921
Practice Address - Country:US
Practice Address - Phone:502-272-5034
Practice Address - Fax:502-272-5117
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200340860Medicaid
KY64257769Medicaid
KY0048442Medicare PIN
KY0601226Medicare PIN
KY64257769Medicaid
KY0766106Medicare PIN
KY1271226Medicare PIN
KY0523927Medicare PIN
IN200340860Medicaid
KY0631232Medicare PIN