Provider Demographics
NPI:1457394934
Name:REIDY, JAMES E (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:REIDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:303 S MAIN
Practice Address - Street 2:SUITE 212
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2160
Practice Address - Country:US
Practice Address - Phone:574-254-0800
Practice Address - Fax:574-254-0812
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01026919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100221910Medicaid
INC25569Medicare UPIN
IN187670DMedicare PIN
IN100221910Medicaid