Basic Information
| Provider Information | |||||||||
| NPI: | 1679786354 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REARDON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4145 CARMICHAEL ROAD | ||||||||
| Address2: | MONTGOMERY CANCER CENTER | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361062803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342737000 | ||||||||
| FaxNumber: | 3342732386 | ||||||||
| Practice Location | |||||||||
| Address1: | 4145 CARMICHAEL ROAD | ||||||||
| Address2: | MONTGOMERY CANCER CENTER | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361062803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342737000 | ||||||||
| FaxNumber: | 3342732386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2007 | ||||||||
| LastUpdateDate: | 06/24/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 25742 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 111323 | 05 | AL | MEDICAID |