Basic Information
| Provider Information | |||||||||
| NPI: | 1881642551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 RESEARCH DR | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665033049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855394644 | ||||||||
| FaxNumber: | 7855398010 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 RESEARCH DR | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665033049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7855394644 | ||||||||
| FaxNumber: | 7855398010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | G63930 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | M-11533 | ID | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 42180 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 04-40715 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | P01203003 | 01 | ID | MCRR | OTHER |