Provider Demographics
NPI:1972519171
Name:REIS, GREGORY (PT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:REIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 PROGRESS RD STE 111
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6630
Mailing Address - Country:US
Mailing Address - Phone:217-222-6800
Mailing Address - Fax:217-222-0037
Practice Address - Street 1:4800 MAINE ST # 48-100
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5875
Practice Address - Country:US
Practice Address - Phone:217-222-6800
Practice Address - Fax:217-222-0037
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-006186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16368Medicare PIN
ILL84468Medicare PIN