Provider Demographics
NPI:1013942549
Name:REYNOLDS, EDWARD ROGER JR (PAC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:ROGER
Last Name:REYNOLDS
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-8175
Mailing Address - Country:US
Mailing Address - Phone:803-775-4469
Mailing Address - Fax:803-775-4981
Practice Address - Street 1:560 CONSTITUTION DR STE 200
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29154-8175
Practice Address - Country:US
Practice Address - Phone:803-775-4469
Practice Address - Fax:803-775-4981
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC771207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P62906Medicare UPIN