Provider Demographics
NPI:1639155534
Name:REYNOLDS, ALBERT LEE (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:LEE
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13755 CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60445-1824
Mailing Address - Country:US
Mailing Address - Phone:708-385-2400
Mailing Address - Fax:708-385-7840
Practice Address - Street 1:901 MC CLINTOCK DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0844
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-654-4253
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036065172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065172Medicaid
IL347711Medicare PIN
IL746480Medicare PIN
IL347710Medicare PIN
IL347713Medicare PIN
ILD13984Medicare UPIN