Healthcare Provider Details

I. General information

NPI: 1942257647
Provider Name (Legal Business Name): PRIMITIVO I. REYNALDO, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 W INNOVATION DR SUITE 700
MILWAUKEE WI
53226-4825
US

IV. Provider business mailing address

10200 W INNOVATION DR SUITE 700
MILWAUKEE WI
53226-4825
US

V. Phone/Fax

Practice location:
  • Phone: 414-302-9196
  • Fax:
Mailing address:
  • Phone: 414-302-9196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: PRIMITIVO I REYNALDO
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 414-302-9196