Healthcare Provider Details

I. General information

NPI: 1225662547
Provider Name (Legal Business Name): RYAN THOMAS RIESSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 475
GRAFENWOEHR BAVARIA
92655
DE

IV. Provider business mailing address

BLDG 475
GRAFENWOEHR BAVARIA
92655
DE

V. Phone/Fax

Practice location:
  • Phone: 314-950-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101026462
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: