Provider Demographics
NPI:1952900409
Name:REAVY, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REAVY
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 1:90 SKOKIE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3054
Mailing Address - Country:US
Mailing Address - Phone:773-835-9386
Mailing Address - Fax:
Practice Address - Street 1:90 SKOKIE BLVD
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3054
Practice Address - Country:US
Practice Address - Phone:773-835-9386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL965506042081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine