MEDICARE: ROBERT B. REYNOLDS DO

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	2084P0800X	Psychiatry Physician	11924153-1204	UT

General Provider Information

NPI Number	:	1417418138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT B. REYNOLDS DO

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5770 S 250 E STE 300
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-8110
Country	:	US
Telephone Number	:	801-314-2500
Fax Number	:	801-314-2501

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

Provider Enumeration Date	:	03/26/2019
Last Update Date	:	06/16/2023

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