Provider Demographics
NPI:1841281706
Name:REYNOLDS-FREEMAN, CAROL IVY (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:IVY
Last Name:REYNOLDS-FREEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 REISTERSTOWN RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6320
Mailing Address - Country:US
Mailing Address - Phone:410-602-9850
Mailing Address - Fax:410-602-9857
Practice Address - Street 1:4 W ROLLING CROSSROADS
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21228-6280
Practice Address - Country:US
Practice Address - Phone:410-869-0100
Practice Address - Fax:410-869-0460
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00279582080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MH316481100Medicaid
MDX963OtherPROVIDER ID
MDX963OtherPROVIDER ID