Provider Demographics
NPI:1992494702
Name:REYNOLDS, MICHAEL SCOTT (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:500 W FORT ST # B.116
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4501
Mailing Address - Country:US
Mailing Address - Phone:208-422-1165
Mailing Address - Fax:208-422-1496
Practice Address - Street 1:500 W FORT ST # B.116
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1165
Practice Address - Fax:208-422-1496
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDMRM-23482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry