Provider Demographics
NPI:1609876770
Name:BUTLER, RENI S (MD)
Entity Type:Individual
Prefix:
First Name:RENI
Middle Name:S
Last Name:BUTLER
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 1:1800 HOLLISTER DR
Mailing Address - Street 2:SUITE G-18
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5264
Mailing Address - Country:US
Mailing Address - Phone:847-918-1462
Mailing Address - Fax:847-968-4311
Practice Address - Street 1:1800 HOLLISTER DR
Practice Address - Street 2:SUITE G-18
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5264
Practice Address - Country:US
Practice Address - Phone:847-918-1462
Practice Address - Fax:847-968-4311
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360961022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212545OtherGROUP PTAN
IL036-096102OtherSTATE LICENSE
IL202926OtherGROUP PTAN
ILG63898Medicare UPIN
IL202926003Medicare PIN
IL212545016Medicare PIN