Provider Demographics
NPI:1700107240
Name:REISER, RAYMOND A (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:REISER
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 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-8000
Mailing Address - Fax:843-663-8123
Practice Address - Street 1:4303 LIVE OAK DRIVE
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566
Practice Address - Country:US
Practice Address - Phone:816-663-8000
Practice Address - Fax:843-663-8123
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36624208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC366240Medicaid
SCSC37201879Medicare PIN