Provider Demographics
NPI:1134326226
Name:DANIEL J REICHENBACH MD PC
Entity Type:Organization
Organization Name:DANIEL J REICHENBACH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:REICHENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-265-0492
Mailing Address - Street 1:3226 HAMPTON AVE
Mailing Address - Street 2:STE B
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4225
Mailing Address - Country:US
Mailing Address - Phone:912-265-0492
Mailing Address - Fax:
Practice Address - Street 1:3020 SHRINE RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4743
Practice Address - Country:US
Practice Address - Phone:912-267-0533
Practice Address - Fax:912-267-7313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056472208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11625808OtherCAQH
GA10062814OtherAMERIGROUP
GA344048OtherWELLCARE
GAI32721Medicare UPIN
GA02BDHVSMedicare ID - Type Unspecified
GAGRP8152Medicare PIN