Healthcare Provider Details

I. General information

NPI: 1457394934
Provider Name (Legal Business Name): JAMES E REIDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S MAIN SUITE 212
MISHAWAKA IN
46544-2160
US

IV. Provider business mailing address

707 CEDAR ST STE 200
SOUTH BEND IN
46617-2057
US

V. Phone/Fax

Practice location:
  • Phone: 574-254-0800
  • Fax: 574-254-0812
Mailing address:
  • Phone: 574-335-8707
  • Fax: 574-335-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01026919
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: