Provider Demographics
NPI:1972682821
Name:REARDON, BRIAN S (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:REARDON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 LEYLAND VW
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3575
Mailing Address - Country:US
Mailing Address - Phone:952-746-2080
Mailing Address - Fax:
Practice Address - Street 1:1300 GODWARD ST NE
Practice Address - Street 2:SUITE 6250
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1741
Practice Address - Country:US
Practice Address - Phone:612-378-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN200P9REOtherBLUE CROSS