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General NPI Number Information
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NPI Number | 1124339734
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Entity Type | Individual
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Provider Name | ETHAN EMERSON REYNOLDS M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/29/2010
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Last Update Date | 05/27/2016
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Provider Practice Location Address
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Address Line | 1 MEMORIAL DR DEPARTMENT OF ANESTHESIOLOGY
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City | ALTON
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State | IL
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Zip | 62002-6722
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Country | US
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Telephone | 423-620-9324
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Fax |
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Provider Business Mailing Address
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Address Line | 2569 TROSSOCK LN
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City | SAINT LOUIS
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State | MO
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Zip | 63122-5025
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Country | US
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Telephone | 423-620-9324
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 2010020282
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License Number State | MO
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