Provider Demographics
NPI:1639372717
Name:REYNOLDS, STEWART
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13135 GLENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-1486
Mailing Address - Country:US
Mailing Address - Phone:313-839-2479
Mailing Address - Fax:
Practice Address - Street 1:1475 E. OUTER DRIVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205
Practice Address - Country:US
Practice Address - Phone:313-371-0055
Practice Address - Fax:313-371-1409
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist