Provider Demographics
NPI:1023028131
Name:W. EMERY REYNOLDS, M.D., PLLC
Entity Type:Organization
Organization Name:W. EMERY REYNOLDS, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNERSHIP
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EMERY
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-755-3540
Mailing Address - Street 1:PO BOX 268947
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8947
Mailing Address - Country:US
Mailing Address - Phone:405-321-5683
Mailing Address - Fax:405-329-0486
Practice Address - Street 1:4120 W MEMORIAL RD STE 208
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9322
Practice Address - Country:US
Practice Address - Phone:405-755-3540
Practice Address - Fax:405-755-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13840174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100123830AMedicaid
OKD35189Medicare UPIN
OK100123830AMedicaid
OK300522116Medicare ID - Type UnspecifiedGROUP