Provider Demographics
NPI:1861453383
Name:REYNOLDS, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
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:PO BOX 751395
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1395
Mailing Address - Country:US
Mailing Address - Phone:843-237-3378
Mailing Address - Fax:843-237-5073
Practice Address - Street 1:301 YADKIN ST
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3441
Practice Address - Country:US
Practice Address - Phone:843-237-3378
Practice Address - Fax:843-237-5073
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC71356OtherBCBS
NC8971356Medicaid
NCC86135Medicare UPIN
NC71356OtherBCBS