Provider Demographics
NPI:1073776456
Name:REYNOLD M JOHN, MD, PC
Entity Type:Organization
Organization Name:REYNOLD M JOHN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REYNOLD
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:586-286-1163
Mailing Address - Street 1:936 JORDAN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5628
Mailing Address - Country:US
Mailing Address - Phone:248-879-9438
Mailing Address - Fax:
Practice Address - Street 1:43171 DALCOMA DR STE 6
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-6307
Practice Address - Country:US
Practice Address - Phone:586-286-1163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRJ405724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301094Medicaid
MI0N60130Medicare PIN
MIE49385Medicare UPIN