Provider Demographics
NPI:1447243712
Name:REARDON, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:REARDON
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:PO BOX 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-633-1010
Mailing Address - Fax:252-224-3071
Practice Address - Street 1:906 WB MCLEAN BLVD
Practice Address - Street 2:
Practice Address - City:CAPE CARTERET
Practice Address - State:NC
Practice Address - Zip Code:28584-9211
Practice Address - Country:US
Practice Address - Phone:252-393-9007
Practice Address - Fax:252-393-9921
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801035207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10590OtherBLUE CROSS
NC8910590Medicaid
NC2259079BOtherMEDICARE PTAN
NC10590OtherBLUE CROSS
NC8910590Medicaid