Provider Demographics
NPI:1487627139
Name:REYNOLDS, DERMOT M (MD)
Entity Type:Individual
Prefix:DR
First Name:DERMOT
Middle Name:M
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 1:5301 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2260
Mailing Address - Country:US
Mailing Address - Phone:607-798-5971
Mailing Address - Fax:315-833-9998
Practice Address - Street 1:5301 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2260
Practice Address - Country:US
Practice Address - Phone:607-798-5971
Practice Address - Fax:315-833-9998
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD422314207X00000X
NY250206-01207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00120718OtherRR MEDICARE PIN
NY1487627139Medicaid
PAGU039978OtherPA MEDICARE GROUP
PA1008319990001Medicaid
NY02521846Medicaid
PACC9269OtherRR MEDICARE GROUP
PAPA MEDICARE GROUPOtherGU039809
I02025Medicare UPIN
PA076949N9SMedicare PIN