Basic Information
| Provider Information | |||||||||
| NPI: | 1255324976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REIDY | ||||||||
| FirstName: | BRIDGET | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 458 | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491200458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694717741 | ||||||||
| FaxNumber: | 2694711581 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 MEADOWBROOK ROAD | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490229069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699854441 | ||||||||
| FaxNumber: | 2699854494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2005 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 407192 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QG0300X | 4301407192 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | P112580 | 01 | MI | BCN | OTHER | 080817663 | 01 | MI | BCBS | OTHER | 4447105 | 05 | MI | MEDICAID | 3103680 | 05 | OH | MEDICAID |