MEDICARE: PAUL REITMAN PHD

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	103T00000X	Psychologist	LP0377	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	984241007131	OTHER	MN	PREFERRED ONE
2	41745RE	OTHER	MN	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720010366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL REITMAN PHD

Provider Business Mailing Address
First Line	:	3230 ORCHARD CT
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-5385
Country	:	US
Telephone Number	:	612-508-9390
Fax Number	:

Provider Business Practice Location Address
First Line	:	4663 WHITE BEAR PKWY
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3300
Country	:	US
Telephone Number	:	612-508-9390
Fax Number	:

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

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	04/30/2015

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