Provider Demographics
NPI:1154365575
Name:REESE, EVAN C JR (MD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:C
Last Name:REESE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 B RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902
Mailing Address - Country:US
Mailing Address - Phone:843-524-3015
Mailing Address - Fax:813-524-3020
Practice Address - Street 1:1251 B RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-524-3015
Practice Address - Fax:813-524-3020
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030154L174400000X
SC31372207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00641759-0001Medicaid
PA641759Medicaid
PARE018182EGFMedicare ID - Type Unspecified
E55051Medicare UPIN
PA00641759-0001Medicaid