Provider Demographics
NPI:1720029283
Name:WILLEMSEN-REID, MARION (DO)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:
Last Name:WILLEMSEN-REID
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2338 W VAN WINKLE WAY STE 2200
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7484
Mailing Address - Country:US
Mailing Address - Phone:309-692-6088
Mailing Address - Fax:
Practice Address - Street 1:2338 W VAN WINKLE WAY STE 2200
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615
Practice Address - Country:US
Practice Address - Phone:309-692-6088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090945208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL050655OtherHEALTH ALLIANCE
ILIL01F4OtherJOHN DEERE
IL0360909453Medicaid
IL472310OtherHEALTHLINK
IL7215059OtherBCBS PPO