Healthcare Provider Details

I. General information

NPI: 1801338769
Provider Name (Legal Business Name): DR. BENJAMIN RIEBESEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5734 COVENTRY LN
FORT WAYNE IN
46804-7141
US

IV. Provider business mailing address

12063 LOWER HUNTINGTON RD
ROANOKE IN
46783-9667
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7973
  • Fax:
Mailing address:
  • Phone: 251-599-6756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28232032A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28232032A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: