Provider Demographics
NPI:1588665434
Name:REEDY, D PETER (MD PA)
Entity Type:Individual
Prefix:
First Name:D
Middle Name:PETER
Last Name:REEDY
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 N CURTIS RD
Mailing Address - Street 2:#307
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1336
Mailing Address - Country:US
Mailing Address - Phone:208-367-7500
Mailing Address - Fax:208-367-7506
Practice Address - Street 1:999 N CURTIS
Practice Address - Street 2:#307
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1333
Practice Address - Country:US
Practice Address - Phone:208-367-7500
Practice Address - Fax:208-367-7506
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-01-23
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IDM-5296207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDL141OtherBLUE CROSS PROVIDER #
IDC36983Medicare UPIN
ID1199801Medicare PIN