Healthcare Provider Details

I. General information

NPI: 1407831191
Provider Name (Legal Business Name): MICHAEL VAN RIESBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 EXECUTIVE PLAZA RD
PENSACOLA FL
32504-8269
US

IV. Provider business mailing address

2411 EXECUTIVE PLAZA RD
PENSACOLA FL
32504-8269
US

V. Phone/Fax

Practice location:
  • Phone: 850-476-0700
  • Fax: 850-476-4300
Mailing address:
  • Phone: 850-476-0700
  • Fax: 850-476-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME 75687
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: