Basic Information
| Provider Information | |||||||||
| NPI: | 1972747244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TALLEY | ||||||||
| FirstName: | REGINALD | ||||||||
| MiddleName: | DONTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147225050 | ||||||||
| FaxNumber: | 6147225058 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147225050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2009 | ||||||||
| LastUpdateDate: | 02/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 35121987 | OH | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P0301X | 35121987 | OH | N | 2081P0010X | 35121987 | OH | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0125385 | 05 | OH | MEDICAID |