Provider Demographics
NPI:1821100504
Name:REIS, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:REIS
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 1:1080 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1256
Mailing Address - Country:US
Mailing Address - Phone:765-914-0946
Mailing Address - Fax:765-939-0138
Practice Address - Street 1:1080 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1256
Practice Address - Country:US
Practice Address - Phone:765-914-0946
Practice Address - Fax:765-939-0138
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24137207R00000X
IN01058750A207R00000X
NC2012-00404207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC7012AOtherMEDICARE PTAN
SC1821100504Medicaid
SCAA2638OtherMEDICARE PTAN
IN200457950Medicaid
NC5920310Medicaid
IN200457950Medicaid
SCAA2638OtherMEDICARE PTAN
SC1821100504Medicaid