MEDICARE: DR. BRIDGET E REIDY M.D.

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician	407192	MI
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	4301407192	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P112580	OTHER	MI	BCN
2	080817663	OTHER	MI	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255324976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIDGET E REIDY M.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 458
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-0458
Country	:	US
Telephone Number	:	269-471-7741
Fax Number	:	269-471-1581

Provider Business Practice Location Address
First Line	:	2550 MEADOWBROOK ROAD
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-9069
Country	:	US
Telephone Number	:	269-985-4441
Fax Number	:	269-985-4494

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

Provider Enumeration Date	:	08/28/2005
Last Update Date	:	04/06/2011

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Directions to “ DR. BRIDGET E REIDY M.D.” Practice Location

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