Provider Demographics
NPI:1033134887
Name:REARDON, KATHLEEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:REARDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60099
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0099
Mailing Address - Country:US
Mailing Address - Phone:704-717-2000
Mailing Address - Fax:704-863-9741
Practice Address - Street 1:101 E W T HARRIS BLVD
Practice Address - Street 2:SUITE 1121
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3485
Practice Address - Country:US
Practice Address - Phone:704-717-2000
Practice Address - Fax:704-863-9741
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28559208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC70711OtherBCBS
NC7970711Medicaid
NC7970711Medicaid