Provider Demographics
NPI:1407956303
Name:REYNOLDS, CAROL E (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:E
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:E
Other - Last Name:REYNOLDS-NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4 GLEN COVE DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4235
Mailing Address - Country:US
Mailing Address - Phone:207-593-5883
Mailing Address - Fax:207-593-5302
Practice Address - Street 1:4 GLEN COVE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4235
Practice Address - Country:US
Practice Address - Phone:207-593-5883
Practice Address - Fax:207-593-5302
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015481208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H32981Medicare UPIN
MEMM8767Medicare ID - Type Unspecified