MEDICARE: COLLYN REAUME AT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2601000277	MI

General Provider Information

NPI Number	:	1093092660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLYN REAUME AT

Provider Business Mailing Address
First Line	:	1209 E 5TH ST
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-2903
Country	:	US
Telephone Number	:	586-604-7819
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 N BEECH DALY RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-3403
Country	:	US
Telephone Number	:	586-604-7819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2011
Last Update Date	:	11/10/2011

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