Provider Demographics
NPI:1811553241
Name:REID, JONATHAN-ERLE CHRISTIAN
Entity Type:Individual
Prefix:
First Name:JONATHAN-ERLE
Middle Name:CHRISTIAN
Last Name:REID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3249 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:965 PRAIRIE CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3671
Practice Address - Country:US
Practice Address - Phone:952-995-8780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036161672207P00000X
MN74098207PS0010X
IL036.161672207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine