1902196090 NPI number — ADAM SCOTT REYNOLDS M.D.

Table of content: ADAM SCOTT REYNOLDS M.D. (NPI 1902196090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902196090 NPI number — ADAM SCOTT REYNOLDS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
ADAM
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
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:
1902196090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 PARKMAN ST.
Provider Second Line Business Mailing Address:
WANG 340
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-726-8810
Provider Business Mailing Address Fax Number:
617-726-3441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 PARKMAN ST.
Provider Second Line Business Practice Location Address:
WANG 340
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-726-8810
Provider Business Practice Location Address Fax Number:
617-726-3441
Provider Enumeration Date:
04/11/2011

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: 2084N0400X , with the licence number:  52506 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 167135 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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