Healthcare Provider Details

I. General information

NPI: 1891847950
Provider Name (Legal Business Name): AUDREY REID AND ASSOCIATES,A MEDICAL GROUP,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE STE 110
PASADENA CA
91105-3150
US

IV. Provider business mailing address

800 FAIRMOUNT AVE STE 110
PASADENA CA
91105-3150
US

V. Phone/Fax

Practice location:
  • Phone: 626-243-9000
  • Fax: 626-795-1269
Mailing address:
  • Phone: 626-243-9000
  • Fax: 626-795-1269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC32644
License Number StateCA

VIII. Authorized Official

Name: MS. BEVERLY ANNE JOHNSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-243-9000