1417932351 NPI number — DR. FREDDIE REYNOLDS MD

Table of content: DR. FREDDIE REYNOLDS MD (NPI 1417932351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417932351 NPI number — DR. FREDDIE REYNOLDS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
FREDDIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1417932351
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 S LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29072-3715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-359-3236
Provider Business Mailing Address Fax Number:
803-359-5233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 SUNSET BLVD
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-3494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-359-3236
Provider Business Practice Location Address Fax Number:
803-359-5233
Provider Enumeration Date:
12/14/2005

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: 207V00000X , with the licence number:  111926 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GP3626 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 542091608 . This is a "BCBS OF SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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