Basic Information
| Provider Information | |||||||||
| NPI: | 1811090780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REID | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | NEIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605421695 | ||||||||
| FaxNumber: | 6605420363 | ||||||||
| Practice Location | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605421695 | ||||||||
| FaxNumber: | 6605421944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 2005018441 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 2005018441 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 209427608 | 05 | MO | MEDICAID | 1811090780 | 05 | MO | MEDICAID |