Provider Demographics
NPI:1700805553
Name:REYNOLDS, GEORGE M (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
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 1:1040 RIVER OAKS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9530
Mailing Address - Country:US
Mailing Address - Phone:601-936-5311
Mailing Address - Fax:601-936-5313
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-936-5311
Practice Address - Fax:601-936-5313
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10138207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012187Medicaid
753068151016OtherTRICARE
753068151OtherMHP
753068151OtherUHC
753068151OtherUHC
MS00012187Medicaid
060028584Medicare PIN
753068151016OtherTRICARE
512I060063Medicare PIN