Provider Demographics
NPI:1316776933
Name:MCREYNOLDS MEDICAL ENTERPRISES LLC
Entity type:Organization
Organization Name:MCREYNOLDS MEDICAL ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCREYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-729-1274
Mailing Address - Street 1:868 ULULANI ST STE 108
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-3913
Mailing Address - Country:US
Mailing Address - Phone:765-729-1274
Mailing Address - Fax:
Practice Address - Street 1:868 ULULANI ST STE 108
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3913
Practice Address - Country:US
Practice Address - Phone:765-729-1274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI001266Medicaid
HIR057879OtherUHA
HI1659767275OtherTRICARE PPO
HISMXPR0059333OtherALOHACARE