1790954634 NPI number — DR. JEREMY E REIDY DOM, AP, L.AC

Table of content: MR. WILLIE WADE (NPI 1104953793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790954634 NPI number — DR. JEREMY E REIDY DOM, AP, L.AC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REIDY
Provider First Name:
JEREMY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DOM, AP, L.AC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POLCYN
Provider Other First Name:
JEREMY
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790954634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 W EDWIN ST
Provider Second Line Business Mailing Address:
THE REIDY CENTER FOR ALTERNATIVE MEDICINE & WELLNESS
Provider Business Mailing Address City Name:
WILLIAMSPORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17701-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-322-6824
Provider Business Mailing Address Fax Number:
570-322-3733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 W EDWIN ST
Provider Second Line Business Practice Location Address:
THE REIDY CENTER FOR ALTERNATIVE MEDICINE & WELLNESS
Provider Business Practice Location Address City Name:
WILLIAMSPORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17701-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-322-6824
Provider Business Practice Location Address Fax Number:
570-322-3733
Provider Enumeration Date:
02/25/2008

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: 171100000X , with the licence number:  AP2482 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X , with the licence number: AK000913 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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