Healthcare Provider Details

I. General information

NPI: 1265543060
Provider Name (Legal Business Name): ANGELA B REESE M.D., P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 W TUGALO ST
TOCCOA GA
30577-2360
US

IV. Provider business mailing address

PO BOX 335
TOCCOA GA
30577-1405
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-1309
  • Fax: 706-886-6132
Mailing address:
  • Phone: 706-886-1309
  • Fax: 706-886-6132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number047514
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000833049A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier336360
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerWELLCARE
# 3
IdentifierG90082
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 4
Identifier1005606
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerAMERIGROUP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: