Basic Information
| Provider Information | |||||||||
| NPI: | 1578597043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REIS | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 443 LAUREL OAK RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445422273 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 39TH AND FILBERT STREETS | ||||||||
| Address2: | MEDICAL ARTS BUILDING, SUITE 212 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156628978 | ||||||||
| FaxNumber: | 2156625940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD049808L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25MA06148200 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001446042 | 05 | PA | MEDICAID |