Provider Demographics
NPI:1336300466
Name:REYNOLDS PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:REYNOLDS PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-823-9777
Mailing Address - Street 1:1531 E BRADFORD PKWY
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6566
Mailing Address - Country:US
Mailing Address - Phone:417-823-9777
Mailing Address - Fax:417-823-9731
Practice Address - Street 1:1531 E BRADFORD PKWY
Practice Address - Street 2:SUITE 215
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6566
Practice Address - Country:US
Practice Address - Phone:417-823-9777
Practice Address - Fax:417-823-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107745174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201291408Medicaid
MO201291408Medicaid
MO000014637Medicare PIN