Basic Information
| Provider Information | |||||||||
| NPI: | 1902887409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | DIEDRE | ||||||||
| MiddleName: | ANN MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LEHIGH AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191251012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157078496 | ||||||||
| FaxNumber: | 2157074086 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E LEHIGH AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191251012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157078496 | ||||||||
| FaxNumber: | 2157074086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 03/30/2010 | ||||||||
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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 | 2084P0800X | 037092 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD438693 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 001370923 | 05 | CT | MEDICAID |