Healthcare Provider Details

I. General information

NPI: 1508982299
Provider Name (Legal Business Name): JAY RISEMAN MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2524 FARRAGUT DR SUITE C
SPRINGFIELD IL
62704-8400
US

IV. Provider business mailing address

2524 FARRAGUT DR SUITE C
SPRINGFIELD IL
62704-8400
US

V. Phone/Fax

Practice location:
  • Phone: 217-546-8711
  • Fax: 217-546-8720
Mailing address:
  • Phone: 217-546-8711
  • Fax: 217-546-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. JAY A RISEMAN
Title or Position: OFFICER
Credential: MD
Phone: 217-629-8711