Healthcare Provider Details

I. General information

NPI: 1285364604
Provider Name (Legal Business Name): RILEY MICHAEL EISENBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S NATIONAL AVE
SPRINGFIELD MO
65897-0001
US

IV. Provider business mailing address

505 E SAINT LOUIS ST APT 219A
SPRINGFIELD MO
65806-2500
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: