Healthcare Provider Details

I. General information

NPI: 1013135615
Provider Name (Legal Business Name): BRUCE E REIDENBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 STONEYCREST RD
RYE NY
10580-4132
US

IV. Provider business mailing address

1 STONEYCREST RD
RYE NY
10580-4132
US

V. Phone/Fax

Practice location:
  • Phone: 914-925-2597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number169073
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61086
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: