MEDICARE: DR. KENNETH HOWARD REYNOLDS MD

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	207R00000X	Internal Medicine Physician	14826	CO
2	207R00000X	Internal Medicine Physician	09598	GA
3	207R00000X	Internal Medicine Physician	M7415	ID

General Provider Information

NPI Number	:	1205001658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH HOWARD REYNOLDS MD

Provider Business Mailing Address
First Line	:	PO BOX 2239
Second Line	:
City	:	CRESTED BUTTE
State	:	CO
Zip	:	81224
Country	:	US
Telephone Number	:	970-349-7341
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 WHETSTONE DR
Second Line	:
City	:	MOUNT CRESTED BUTTE
State	:	CO
Zip	:	81225
Country	:	US
Telephone Number	:	970-349-7341
Fax Number	:

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

Provider Enumeration Date	:	04/28/2008
Last Update Date	:	04/28/2008

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