Provider Demographics
NPI:1932180387
Name:REID, WALTER SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:SCOTT
Last Name:REID
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:900 MAIN ST
Mailing Address - Street 2:SUITE 530
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-672-5975
Mailing Address - Fax:309-655-1678
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 530
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-672-5975
Practice Address - Fax:309-655-1678
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360959332086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095933Medicaid
L73928Medicare ID - Type Unspecified
H07091Medicare UPIN