Healthcare Provider Details

I. General information

NPI: 1689674830
Provider Name (Legal Business Name): SUSAN MARIE REIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/22/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

1212 10TH ST SUITE A
SNOHOMISH WA
98290-2070
US

IV. Provider business mailing address

1212 10TH ST SUITE A
SNOHOMISH WA
98290-2070
US

V. Phone/Fax

Practice location:
  • Phone: 360-568-3627
  • Fax: 360-568-8522
Mailing address:
  • Phone: 360-568-3627
  • Fax: 360-568-8522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberWA24446
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: