Provider Demographics
NPI:1265472898
Name:REYNOLDS, PATRICE W (MD)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:W
Last Name:REYNOLDS
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 1:432 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4004
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:5000 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5137
Practice Address - Country:US
Practice Address - Phone:215-726-9807
Practice Address - Fax:215-726-0424
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425381208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0492593OtherCIGNA
PA101142943-01OtherAMERICHOICE
PA101142943Medicaid
PA30021095OtherKEYSTONE MERCY
PA1659165OtherHIGHMARK BLUE SHIELD
PA1659165OtherPERSONAL CHOICE
PA2335423000OtherIBC, KEYSTONE
PA3767374OtherAETNA
PA03226OtherHEALTH PARTNERS
PA9376776OtherPHCS
PA2490677OtherUNITED HEALTHCARE
PA2335423000OtherIBC, KEYSTONE
PAI21758Medicare UPIN