Healthcare Provider Details

I. General information

NPI: 1629280995
Provider Name (Legal Business Name): REEDADA S IDRISS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: REED S IDRISS MD

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HOSPITAL AVE
DANBURY CT
06810-6099
US

IV. Provider business mailing address

5120 DUVALL PL NW
ROCHESTER MN
55901-3821
US

V. Phone/Fax

Practice location:
  • Phone: 203-739-7000
  • Fax:
Mailing address:
  • Phone: 507-287-1831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number49753
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number047400
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: