Provider Demographics
NPI:1205490224
Name:REID, MARY KATHLEEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:REID
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 RHODE ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3758
Mailing Address - Country:US
Mailing Address - Phone:248-231-9870
Mailing Address - Fax:
Practice Address - Street 1:1181 N MILFORD RD STE 100
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1061
Practice Address - Country:US
Practice Address - Phone:248-685-0444
Practice Address - Fax:248-684-0900
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301509335207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program