Provider Demographics
NPI:1124211503
Name:HERNAN REYES MD SC
Entity Type:Organization
Organization Name:HERNAN REYES MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HERNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-656-9247
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-0129
Mailing Address - Country:US
Mailing Address - Phone:800-843-0355
Mailing Address - Fax:815-834-1300
Practice Address - Street 1:5610 W CERMAK RD
Practice Address - Street 2:UNIT #2
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2219
Practice Address - Country:US
Practice Address - Phone:708-656-9247
Practice Address - Fax:708-656-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01638280OtherBLUE CROSS BLUE SHIELD
IL01638280OtherBLUE CROSS BLUE SHIELD