Provider Demographics
NPI:1285687467
Name:REYELTS, FREDRIC ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:ALAN
Last Name:REYELTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 BROADWAY AVE NW STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4496
Mailing Address - Country:US
Mailing Address - Phone:616-685-7500
Mailing Address - Fax:616-685-7511
Practice Address - Street 1:801 BROADWAY AVE NW STE 105
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4496
Practice Address - Country:US
Practice Address - Phone:616-685-7500
Practice Address - Fax:616-785-7511
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010515112084P0800X, 2084P0805X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3415813Medicaid
MI4106189Medicaid
MI4593050Medicaid
MI4878865Medicaid
MI2995094Medicaid
MI4155657Medicaid
MI4593060Medicaid
MIM69390072Medicare ID - Type Unspecified
MIE50451Medicare UPIN
MI2995094Medicaid
MI4593060Medicaid