NPIMap

Individual provider Active NPI

Brennan T Reeder, PA-C

  • Physician Assistant
  • Rockford, IL
National Provider Identifier
1063991958
Registry record updated Sep 17, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
085007247 Issued in IL
Practice address
1200 W State St
Rockford, IL 61102-2112
Phone
(815) 490-1600
Fax
(815) 490-1881
NPI assigned
Aug 10, 2018
Last updated
Sep 17, 2019By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 17, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 085007247 IL Primary

Addresses

Primary practice location

1200 W State St
Rockford, IL 61102-2112

Mailing address

1200 West State Street
Rockford, IL 61102-2112
Phone (815) 490-1600

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20231013000195 IL Practitioner - Physician Assistant 9436582673 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Mendota Community HospitalGroup PAC ID 2264335777, 51 clinicians

Practice addresses (Care Compare)

1404 Washington St
Mendota, IL 61342-1471
Phone (815) 539-1825

1405 E 12TH St
Suite 700
Mendota, IL 61342-9010
Phone (815) 539-2663

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
085007247ILMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Mendota Community Hospital CurrentSince Oct 1, 2023 Accepting new patients
Mendota Community Hospital Physician Assistant CurrentSince Oct 1, 2023 Accepting new patients
Mendota Community Hospital Past Accepting new patients
Osf Multi-Specialty Group Past Accepting new patients

Locations

1404 Washington St
Mendota, IL 61342
Phone (815) 538-1825

1405 E 12th St
Ste 600
Mendota, IL 61342
Phone (815) 538-7200

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1533859200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1568678400000",
    "number": "1063991958",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 WEST STATE STREET",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611022112",
            "telephone_number": "815-490-1600",
            "fax_number": "815-815-1881"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1200 W STATE ST",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611022112",
            "telephone_number": "815-490-1600",
            "fax_number": "815-490-1881"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "REEDER",
        "first_name": "BRENNAN",
        "middle_name": "T",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-08-10",
        "last_updated": "2019-09-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085007247",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rockford, IL

Sources for this page

Verify at the official NPI Registry.