Healthcare Provider Details

I. General information

NPI: 1295771798
Provider Name (Legal Business Name): THOMAS JON RISHAVY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 LONDON RD SUITE 101
DULUTH MN
55805-2433
US

IV. Provider business mailing address

1420 LONDON RD SUITE 101
DULUTH MN
55805-2433
US

V. Phone/Fax

Practice location:
  • Phone: 218-724-7363
  • Fax: 218-724-6199
Mailing address:
  • Phone: 218-724-7363
  • Fax: 218-724-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number45103
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: