Basic Information
| Provider Information | |||||||||
| NPI: | 1891889978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REARDON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1520 | ||||||||
| Address2: | STE 1230 | ||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970588003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412987971 | ||||||||
| FaxNumber: | 5412966431 | ||||||||
| Practice Location | |||||||||
| Address1: | 2790 CLAY EDWARDS DR | ||||||||
| Address2: | STE 1230 | ||||||||
| City: | NORTH KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641163276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162149300 | ||||||||
| FaxNumber: | 8162149330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 106191 | MO | Y | Other Service Providers | Specialist | 332B00000X | 106191 | MO | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | 106191 | MO | N | Suppliers | Prosthetic/Orthotic Supplier |
No ID Information.