Provider Demographics
NPI:1639583586
Name:REILLY, LAUREN MARISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:MARISSA
Last Name:REILLY
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 1:1936 N CLARK ST
Mailing Address - Street 2:APT 728
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5454
Mailing Address - Country:US
Mailing Address - Phone:239-290-2739
Mailing Address - Fax:
Practice Address - Street 1:1936 N CLARK ST APT 728
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:239-290-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70260207L00000X
IL125065474207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639583586Medicaid