Provider Demographics
NPI:1891229175
Name:REYNOLDS, SAMUEL BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:BENJAMIN
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 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-4720
Mailing Address - Fax:
Practice Address - Street 1:401 E CHESTNUT ST UNIT 310
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5703
Practice Address - Country:US
Practice Address - Phone:502-588-4720
Practice Address - Fax:502-588-7831
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYTP269207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100601580Medicaid