Provider Demographics
NPI:1417916362
Name:REYNOLDS, SALLY LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:LOUISE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - Street 2:225 EAST CHICAGO AVENUE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:800-543-7362
Mailing Address - Fax:312-227-9475
Practice Address - Street 1:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - Street 2:225 EAST CHICAGO AVENUE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:800-543-7362
Practice Address - Fax:312-227-9475
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360713392080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036071339Medicaid
E18620Medicare UPIN