Healthcare Provider Details

I. General information

NPI: 1689621237
Provider Name (Legal Business Name): RED RIVER NEPHROLOGY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N HIGHLAND AVE SUITE 105
SHERMAN TX
75092-7378
US

IV. Provider business mailing address

321 N HIGHLAND AVE SUITE 105
SHERMAN TX
75092-7378
US

V. Phone/Fax

Practice location:
  • Phone: 903-893-7170
  • Fax: 903-893-4372
Mailing address:
  • Phone: 903-893-7170
  • Fax: 903-893-4372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberH6541
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberH6541
License Number StateTX

VIII. Authorized Official

Name: DR. DAVID GLENN REYNOLDS I
Title or Position: PRESIDENT/PROVIDER
Credential: MD
Phone: 903-893-7170