Provider Demographics
NPI:1760486526
Name:REYNOLDS, MICHAEL GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
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 1:1602 W 15TH AVE
Mailing Address - Street 2:STE B
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-5672
Mailing Address - Country:US
Mailing Address - Phone:620-342-6989
Mailing Address - Fax:620-342-2262
Practice Address - Street 1:1602 W 15TH AVE
Practice Address - Street 2:STE B
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-5672
Practice Address - Country:US
Practice Address - Phone:620-342-6989
Practice Address - Fax:620-342-2262
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100164440AMedicaid
47-1424576OtherTAX ID
48-0792406OtherOLD TAX ID
47-1424576OtherTAX ID