Provider Demographics
NPI:1265418347
Name:REYNOLDS, PATRICK SHAWN (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:SHAWN
Last Name:REYNOLDS
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-9016
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-9016
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96 010442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7101431Medicaid
NC891198RMedicaid
SCQ01048Medicaid
130025236OtherRR MEDICARE
WV2004310000Medicaid
1198ROtherBCBS
87355OtherMEDCOST
28663OtherPARTNERS
7240386OtherAETNA
1198ROtherBCBS
87355OtherMEDCOST