Provider Demographics
NPI:1942313788
Name:REA, REBECCA SUE (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:REA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:GIBB - HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:NORTH STREET
Mailing Address - State:MI
Mailing Address - Zip Code:48049
Mailing Address - Country:US
Mailing Address - Phone:586-948-5100
Mailing Address - Fax:586-948-5103
Practice Address - Street 1:30500 TWENTY THREE MILE ROAD
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047
Practice Address - Country:US
Practice Address - Phone:586-948-5100
Practice Address - Fax:586-948-5103
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G31623Medicare UPIN
N96990001Medicare ID - Type Unspecified