Healthcare Provider Details

I. General information

NPI: 1003028150
Provider Name (Legal Business Name): JILL WIRTH-RISSMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 01/24/2020
Certification Date: 01/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N CUMMINGS LN
WASHINGTON IL
61571-2181
US

IV. Provider business mailing address

5100 RELIABLE PKWY
CHICAGO IL
60686-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-643-6210
  • Fax:
Mailing address:
  • Phone: 309-672-4809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036119699
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: