1255324976 NPI number — DR. BRIDGET E REIDY M.D.

Table of content: MEGAN KESTER (NPI 1881377315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255324976 NPI number — DR. BRIDGET E REIDY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REIDY
Provider First Name:
BRIDGET
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1255324976
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 458
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NILES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49120-0458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-471-7741
Provider Business Mailing Address Fax Number:
269-471-1581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 MEADOWBROOK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49022-9069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-985-4441
Provider Business Practice Location Address Fax Number:
269-985-4494
Provider Enumeration Date:
08/28/2005

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: 207QG0300X , with the licence number:  407192 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X , with the licence number: 4301407192 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P112580 . This is a "BCN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080817663 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4447105 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3103680 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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