Provider Demographics
NPI:1902926942
Name:REIDMAN, TIMOTHY EDWARD (MOT, OTRL)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:REIDMAN
Suffix:
Gender:M
Credentials:MOT, OTRL
Other - Prefix:MR
Other - First Name:TIMOTHY
Other - Middle Name:EDWARD
Other - Last Name:REIDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOT, OTRL
Mailing Address - Street 1:162 HARTLEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3231
Mailing Address - Country:US
Mailing Address - Phone:207-415-6852
Mailing Address - Fax:
Practice Address - Street 1:162 HARTLEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3231
Practice Address - Country:US
Practice Address - Phone:207-415-6852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT1597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist