Provider Demographics
NPI:1124076278
Name:REYNOLDS, KATHY L (MD)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1450 NW 0090
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55485-0090
Mailing Address - Country:US
Mailing Address - Phone:800-279-1395
Mailing Address - Fax:517-694-6441
Practice Address - Street 1:800 EAST 21ST STREET
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1016
Practice Address - Country:US
Practice Address - Phone:605-322-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD47432080P0203X, 2080P0214X
NC9701856208000000X
NV117122080P0203X
CO383722080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891113PMedicaid
NV002019725Medicaid
CO64900789Medicaid
MN063407700Medicaid
SD6700510Medicaid
CO64900789Medicaid
CO64900789Medicaid