Basic Information
| Provider Information | |||||||||
| NPI: | 1033170949 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REINHEIMER | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 43750 GARFIELD RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862266865 | ||||||||
| FaxNumber: | 5862266880 | ||||||||
| Practice Location | |||||||||
| Address1: | 30795 23 MILE RD | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480475720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869480093 | ||||||||
| FaxNumber: | 5864217500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 01/18/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 4301046162 | MI | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 208000000X | 4301046162 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4373674 | 05 | MI | MEDICAID | 4373807 | 05 | MI | MEDICAID | 4704131 | 05 | MI | MEDICAID |