Provider Demographics
NPI:1093716052
Name:STREET, MAUREEN REYNOLDS (MD)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:REYNOLDS
Last Name:STREET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9060 N BAYSHORE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:ELK RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49629-9435
Mailing Address - Country:US
Mailing Address - Phone:231-498-4552
Mailing Address - Fax:866-920-0420
Practice Address - Street 1:9060 N BAYSHORE DR STE 2
Practice Address - Street 2:
Practice Address - City:ELK RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49629-9435
Practice Address - Country:US
Practice Address - Phone:231-498-4552
Practice Address - Fax:866-920-0420
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126839207Q00000X
MI4301064260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231858Medicare Oscar/Certification
MI114058OtherPREFERRED CHOICES
MI19805OtherHEALTH PLAN
MIP60901OtherBLUE CARE NETWORK
MI0M3260036Medicare UPIN
MIG59861Medicare UPIN
MI4520493Medicaid
MI700F11016OtherBCBS