Provider Demographics
NPI:1336384551
Name:REYNOSO MD MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:REYNOSO MD MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:G
Authorized Official - Last Name:REYNOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-659-1509
Mailing Address - Street 1:8595 E BELL RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1306
Mailing Address - Country:US
Mailing Address - Phone:480-659-1509
Mailing Address - Fax:480-659-0275
Practice Address - Street 1:8595 E BELL RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1306
Practice Address - Country:US
Practice Address - Phone:480-659-1509
Practice Address - Fax:480-659-0275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty