Healthcare Provider Details

I. General information

NPI: 1770781148
Provider Name (Legal Business Name): JASON D RIESINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JASON DAVID RIESINGER MD

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N ROCKTON AVE ROCKFORD HEALTH PHYSICIANS
ROCKFORD IL
61103-3655
US

IV. Provider business mailing address

2400 N ROCKTON AVE ROCKFORD HEALTH PHYSICIANS
ROCKFORD IL
61103-3655
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-3333
  • Fax: 815-968-0360
Mailing address:
  • Phone: 815-971-3333
  • Fax: 815-968-0360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036118261
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number54319
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: