1003815580 NPI number — DR. THOMAS M REYNOLDS M.D.

Table of content: DR. THOMAS M REYNOLDS M.D. (NPI 1003815580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003815580 NPI number — DR. THOMAS M REYNOLDS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
THOMAS
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003815580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2158 NORTHGATE PARK LN
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37415-6957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-870-4900
Provider Business Mailing Address Fax Number:
423-870-5889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2158 NORTHGATE PARK LN
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37415-6957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-870-4900
Provider Business Practice Location Address Fax Number:
423-870-5889
Provider Enumeration Date:
07/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD016274 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 180029644 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3711088 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3031931 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1187690001 . This is a "DMERC GROUP SUPPLIER NUMB" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 3069497 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 62-1701871 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".




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