Provider Demographics
NPI:1942212311
Name:REEVES, MELISSA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:REEVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:HAGLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4501 WEST WESTCHESTER LANE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048
Mailing Address - Country:US
Mailing Address - Phone:847-962-3325
Mailing Address - Fax:847-872-5716
Practice Address - Street 1:4501 WEST WESTCHESTER LANE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-962-3325
Practice Address - Fax:847-872-5716
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100559207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001633810OtherBC PROVIDER NUMBER
IL209634OtherMEDICARE PTAN
IL0001633810OtherBC PROVIDER NUMBER
H17092Medicare UPIN