Basic Information
| Provider Information | |||||||||
| NPI: | 1588633051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142213647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168787662 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 223708 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000527719001 | 01 | BC/BS | OTHER | 3612556 | 01 | IHA | OTHER | 02560061 | 05 | NY | MEDICAID | 00026849001 | 01 | UNIVERA | OTHER | 040908000013 | 01 | FIDELIS | OTHER |