Provider Demographics
NPI:1811990641
Name:REIDY, TERRENCE J (MD)
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:J
Last Name:REIDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 WILTSHIRE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:KEARNEYSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25430-0010
Mailing Address - Country:US
Mailing Address - Phone:304-728-8416
Mailing Address - Fax:304-728-3319
Practice Address - Street 1:1948 WILTSHIRE RD STE 1
Practice Address - Street 2:
Practice Address - City:KEARNEYSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25430-0010
Practice Address - Country:US
Practice Address - Phone:304-728-8416
Practice Address - Fax:304-728-3319
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV14155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0084535000Medicaid
WVWV4235B987Medicare PIN
WVRE0561693Medicare PIN
WVA72329Medicare UPIN