Healthcare Provider Details

I. General information

NPI: 1063589935
Provider Name (Legal Business Name): HANS C. GEISSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

V. Phone/Fax

Practice location:
  • Phone: 909-353-2000
  • Fax:
Mailing address:
  • Phone: 909-353-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberA46120
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberMD60665946
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number170233
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: