Basic Information
Provider Information | |||||||||
NPI: | 1487659876 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REEDY | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | BRENDAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | X | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6107 88TH PL | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794240839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256650118 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 602 INDIANA AVE | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794153364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067758600 | ||||||||
FaxNumber: | 8067758586 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2005 | ||||||||
LastUpdateDate: | 03/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | H8348 | TX | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
ID | Type | State | Issuer | Description | 122327308 | 05 | TX |   | MEDICAID | 122327315 | 05 | TX |   | MEDICAID | 122327306 | 05 | TX |   | MEDICAID | H08KE62101 | 01 | TX | BCBS | OTHER |