Provider Demographics
NPI:1659353803
Name:REINOEHL, PHILLIP GRAYDON (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:GRAYDON
Last Name:REINOEHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:451 HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8242
Practice Address - Country:US
Practice Address - Phone:269-655-3065
Practice Address - Fax:269-655-0585
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIPR4301030440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238601OtherMEDICARE RURAL HEALTH CLINIC NUMBER
MI2972204Medicaid
MICA1068OtherRAILROAD MEDICARE
MICA1068OtherRAILROAD MEDICARE
B45841Medicare UPIN