Provider Demographics
NPI:1770502221
Name:REYNOLDS, CARL R (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:R
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 1:51 N 39TH ST
Mailing Address - Street 2:PHI SUITE 2C
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-9010
Mailing Address - Fax:
Practice Address - Street 1:51 N. 39TH STREET
Practice Address - Street 2:PHI SUITE 2C
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10750900207RC0000X
PAMD429251207RC0000X, 207RC0001X
NC2009-00801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1090Medicaid
SCNC1090Medicaid