Provider Demographics
NPI:1790100220
Name:ROY D REYNOLDS MD PSC
Entity Type:Organization
Organization Name:ROY D REYNOLDS MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:D
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-586-9581
Mailing Address - Street 1:121 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134-2752
Mailing Address - Country:US
Mailing Address - Phone:270-586-9581
Mailing Address - Fax:270-586-6261
Practice Address - Street 1:121 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2752
Practice Address - Country:US
Practice Address - Phone:270-586-9581
Practice Address - Fax:270-586-6261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64193832Medicaid
KY64193832Medicaid