Basic Information
| Provider Information | |||||||||
| NPI: | 1639155534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13755 CICERO AVE | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604451824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083852400 | ||||||||
| FaxNumber: | 7083857840 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 MC CLINTOCK DRIVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6306544253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036065172 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036065172 | 05 | IL | MEDICAID |