Provider Demographics
NPI:1104824598
Name:REACH, BRIAN JAY (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAY
Last Name:REACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E MADISON ST STE 328
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5131
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:300 W OAK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1400
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2021-11-10
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-05-01
Provider Licenses
StateLicense IDTaxonomies
IL036-099587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-099587Medicaid
ILH04942OtherBLUE CROSS BLUE SHIELD
ILH04942OtherCHAMPVA
IL411176OtherHEALTHLINK
ILH04942OtherTRICARE
ILK01261OtherWPS
IL036099587OtherIDPA FEE FOR SERVICE
IL052910OtherHEALTH ALLIANCE
ILH04942OtherUNITED HEALTHCARE RR MEDI
IL036-099587Medicaid