Provider Demographics
NPI:1982913505
Name:REED, ILLENE T (MD)
Entity Type:Individual
Prefix:
First Name:ILLENE
Middle Name:T
Last Name:REED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:218-347-1200
Mailing Address - Fax:218-346-4043
Practice Address - Street 1:1000 CONEY ST W
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2102
Practice Address - Country:US
Practice Address - Phone:218-347-1200
Practice Address - Fax:218-346-4043
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-03-26
Deactivation Date:2010-09-10
Deactivation Code:
Reactivation Date:2010-09-29
Provider Licenses
StateLicense IDTaxonomies
MN43015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H07732Medicare UPIN
080013805Medicare ID - Type Unspecified