Healthcare Provider Details

I. General information

NPI: 1427092410
Provider Name (Legal Business Name): ROBIN RUSSELL REYE SAPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROBIN RUSSELL REYE SAPA-C

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4228 MT. MORRIS RD
COLUMBIAVILLE MI
48421
US

IV. Provider business mailing address

4228 MOUNT MORRIS RD
COLUMBIAVILLE MI
48421-9373
US

V. Phone/Fax

Practice location:
  • Phone: 810-793-2241
  • Fax: 810-793-2587
Mailing address:
  • Phone: 810-793-2241
  • Fax: 810-793-2587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601001893
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: