Provider Demographics
NPI:1184793481
Name:REIDEL, JONATHAN ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:REIDEL
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 1:375 WILLARD AVE
Mailing Address - Street 2:GROVE HILL MEDICAL CENTER
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2300
Mailing Address - Country:US
Mailing Address - Phone:860-666-5167
Mailing Address - Fax:860-665-8168
Practice Address - Street 1:375 WILLARD AVE
Practice Address - Street 2:GROVE HILL MEDICAL CENTER
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2300
Practice Address - Country:US
Practice Address - Phone:860-666-5167
Practice Address - Fax:860-665-8168
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044890208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP3735238OtherOXFORD
CT7615732OtherCIGNA
CT004195930Medicaid
CT227660OtherCONNECTICARE
CT369523OtherWELLCARE MEDICARE
CT001448902Medicaid
CT010044890CT01OtherBCBS & BCFP PROV ID
CT1255448155OtherGHMC GROUP NPI ID
CT1470175OtherAETNA
CT2V8732OtherHEALTH NET
CT227660OtherCONNECTICARE
CT7615732OtherCIGNA
CTC01373Medicare ID - Type UnspecifiedGHMC GROUP CARE ID