Healthcare Provider Details

I. General information

NPI: 1144540022
Provider Name (Legal Business Name): MICHAEL JAMES REARDON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 DUNLOP RD
HUNTINGTON NY
11743-3932
US

IV. Provider business mailing address

41 DUNLOP RD
HUNTINGTON NY
11743-3932
US

V. Phone/Fax

Practice location:
  • Phone: 631-463-5686
  • Fax:
Mailing address:
  • Phone: 631-463-5686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number162904-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: