Provider Demographics
NPI:1033696562
Name:REIDY, KATIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:REIDY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-8709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 PATRIOT BLVD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026
Practice Address - Country:US
Practice Address - Phone:847-475-2273
Practice Address - Fax:847-998-9005
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant