Provider Demographics
NPI:1922614999
Name:REYNOLDS, SCOTT (ATC)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 KATHLEEN CRES
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1469
Mailing Address - Country:US
Mailing Address - Phone:631-766-0534
Mailing Address - Fax:
Practice Address - Street 1:21 KATHLEEN CRES
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-1469
Practice Address - Country:US
Practice Address - Phone:631-766-0534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0024912083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000011183OtherBOC
NY002491OtherNY STATE LICENSURE