Provider Demographics
NPI:1417932351
Name:REYNOLDS, FREDDIE (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDDIE
Middle Name:
Last Name:REYNOLDS
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 1:811 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-3715
Mailing Address - Country:US
Mailing Address - Phone:803-359-3236
Mailing Address - Fax:803-359-5233
Practice Address - Street 1:3020 SUNSET BLVD
Practice Address - Street 2:STE 105
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3494
Practice Address - Country:US
Practice Address - Phone:803-359-3236
Practice Address - Fax:803-359-5233
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC111926207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3626Medicaid
SC542091608OtherBCBS OF SC
SCGP3626Medicaid
SCC61151Medicare UPIN