Healthcare Provider Details

I. General information

NPI: 1942289459
Provider Name (Legal Business Name): MICHAEL J FLEISSNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6810 STATE ROUTE 162 STE 102
MARYVILLE IL
62062-8560
US

IV. Provider business mailing address

6810 STATE ROUTE 162 STE 102
MARYVILLE IL
62062-8560
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-4076
  • Fax:
Mailing address:
  • Phone: 618-288-4076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD100821
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number100821
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036.084308
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: