Healthcare Provider Details

I. General information

NPI: 1083605935
Provider Name (Legal Business Name): ELIZABETH A RIESGRAF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIRCLE
ST CLOUD MN
56303
US

IV. Provider business mailing address

1900 CENTRACARE CIRCLE
ST CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-4917
  • Fax: 320-229-5181
Mailing address:
  • Phone: 320-229-4917
  • Fax: 320-229-5181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24843
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: