=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043277270
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HARRY RICHARD REYNOLDS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2345 CHESTERFIELD AVE SUITE 204
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-345-3570
-----------------------------------------------------
Fax | 304-345-3599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2345 CHESTERFIELD AVE SUITE 204
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-1062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-345-3570
-----------------------------------------------------
Fax | 304-345-3599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | WV14661
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------