Healthcare Provider Details

I. General information

NPI: 1588662639
Provider Name (Legal Business Name): MICHAEL ANTHONY REISIG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 INTERNATIONAL CIR SUITE 140
COLORADO SPRINGS CO
80910-3127
US

IV. Provider business mailing address

340 PRINTERS PKWY
COLORADO SPRINGS CO
80910-3190
US

V. Phone/Fax

Practice location:
  • Phone: 719-632-5700
  • Fax: 719-344-7821
Mailing address:
  • Phone: 719-632-5700
  • Fax: 719-344-7837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5776190-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: