Healthcare Provider Details

I. General information

NPI: 1699710954
Provider Name (Legal Business Name): MATTHEW J RISKEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 SAINT FRANCIS AVE
SHAKOPEE MN
55379-3374
US

IV. Provider business mailing address

PO BOX 46100
PLYMOUTH MN
55446-0100
US

V. Phone/Fax

Practice location:
  • Phone: 952-403-3000
  • Fax:
Mailing address:
  • Phone: 763-553-9920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number44599
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: